Review finds APRNs may outperform physicians | National Nursing News

Review finds APRNs may outperform physicians | National Nursing News

AANP Conference

http://www.lvrj.com/news/sebelius-addresses-5-600-124408819.html

Awesome conference! The lecture where I presented our clinic model received a standing ovation; there are many NPs who are just getting the state authority to practice independently. As you can see from the link above, the federal government is very enthusiastic about NPs. Thanks for your patience while I was gone, and thanks to Lisa for taking over so I could go.

WORKLOAD!

I am so happy to report that the clinic is doing great! I am busier than ever though and trying figure out ways to get out of here on time for dinner.

You may not know this but many of the tasks I provide are not covered by your insurance. Phone calls and emails along with many other duties are considered non-covered benefits. Many providers have chosen to have a yearly non-covered benefits fee of between $100 to $300 per patient, and others have chosen to charge fees for certain services; for now, I fall into the latter category and will post fees for extra work on my website in the next few months.

If any of the next 3 items are completed during an office visit, the fee will be waived, otherwise the fee is $30.

• Referral letters and insurance pre-authorization for specialists visits
• Letters for school, work, jury duty, etc.
• Form completion, including medication pre-authorization, FMLA / short-term disability, DOT physical, sports physical, etc.

I will offer the following services on a fee-for-service basis:

• Virtual visits -- if any email request will take longer than 10 minutes or require a treatment plan / prescription, you will be sent a virtual visit form ($30)
• Phone consult -- this is if you want to speak to me on the phone for medical advice that normally would be discussed at a proper visit ($30 per 15 minutes)
• After-hours phone calls (anytime other than 9am to 5pm on Monday to Friday) -- calling after hours for medical advice and treatment, and keeping you out of Urgent Care or the ER ($40)

So why, you might ask, am I doing this? I know it is hard to believe but there are patients who consistently use the "free" services and don't come in for a visit, and that is not in my business plan. I do always reserve the right to waive the charge, but I just want the policy out there if I need to use it. Would love feedback from all of you! -- Kristina

Call to Action

Many of you already know that I belong to a non-profit organization called Ideal Medical Practices, IMP for short (http://www.idealhealthnetwork.org/). The IMP clinic model is designed to enhance provider-patient relationships, increase face-to-face time with providers and patients, reduce the workload in primary care, and instill patients with a sense of responsibility for their health and their health care dollars. An excerpt from the website is below:

The goal of an Ideal Medical Practice is Ideal care for patients in balanced, ethical and sustainable practices.

Ideal health care rests on a foundation of effective primary care.

1. Effective primary care is based on excellence in access, relationship over time, comprehensive services, and care coordination.
2. Ideal care is defined through patient experience.
   • “I can get care when and how I need it”
   • “I have a PCP who knows me as a person”
   • “My PCP takes care of the bulk of my health care needs”
   • “My PCP coordinates any and all care I need”
3. Balanced, ethical and sustainable practices are defined through Primary Care Provider/PCP experience.
• “I am free to do what is best for my patient”
• “I have the funding and autonomy I need”
• “I have the time I need”
• “I know my patients and can communicate with them effectively”
• “I have the tools, and technology I need”

Briefly, I want to address the above statement because some of the goals are being met, but all the goals are attainable and necessary for our health care system to survive and thrive. I will use Village Family Clinic as the example; I think we do a pretty good job with items #1 and #2, mostly because those are the items over which the provider and patient have control. #3 is where the health care system has control and causes providers the most trouble.

• "I am free to do what is best for my patient" -- Many patients are dealing with high deductible insurances (or no insurance) and cannot always financially afford the best evaluation or treatment. And anyone who has ever waited for a referral to a specialist or pre-authorization for tests or medication knows that the provider does not make the final decision with respect to care.
• "I have the funding and autonomy I need" -- Third party payers (ie -- insurance companies) are the "elephant" in the exam room, due to some of the issues from the last statement, taking away autonomy by creating barriers to increase provider workload and increase patient expense, thus discouraging both from the proper care. I understand that most systems need checks and balances to control quality and cost, but I do 6-8 hours of uncompensated work per week because of these barriers. As far as funding, let's just say there is a reason that doctors are choosing specialties over primary care by a 50 to 1 margin.
• "I have the time I need" -- With the IMP model, I have enough time with patients because I decreased my clinic expenses, so I can generate less revenue and still keep the doors open. Our medical system financially rewards the providers that see the most patients, and not the providers that give the best quality care.
• "I know my patients and can communicate with them effectively" -- This one is no problem, right? Have I mentioned that I LOVE EMAIL! But the privacy police will be after me to comply in the next few years -- the only solution will be a securepatient portal that either you, I or all of us will have to pay for.
• "I have the tools and technology I need" -- Finally most clinics are embracing technology, and that has created competitive prices for electronic health records/systems. This has also created programs that are completely different and cannot "talk" to each other and work together. It is inexcusable that we cannot communicate securely with specialists and hospitals when we can do it with the pharmacies through e-prescribing. I still get almost all patient information from outside the clinic by fax -- talk about not secure; if you are one number off, then your neighbor gets the test results.

Well, there are no perfect solutions, but it is a fact that health care systems with strong primary care as a base have healthier patient populations (Davis, Commonwealth Fund 2007, Wasson, JACM 2006, Moore, JACM 2006). In October 2011, I am going to Washington DC with IMP as the nurse practitioner liaison. We will be advocating for improvements in primary care, and the "hook" is "Primary Care can thrive on $1 a day."

What does that mean for us? If your health care provider (me) was paid $365 per year for each patient (which is about as much as everyone pays per month for insurance), I could make a living with a patient panel of 600 people. I currently have 1200 patients to do the same thing. Obviously this is way oversimplified because some patients need more or less care, but the concept is the same: 80-90% of health care could be done for 1/12 of the price. Hmmmm -- I see that as pleasing to both sides of the aisle in DC.

If any of you have stories about our health care system that I can share with the congressional members in October, please email them to me in the form of a letter. I will take them with me and you will be heard. Thanks!

Kristina

KG and VFC published online!

Here is a link to an article about Village Family Clinic and the technology used to accomplish successful patient care.

http://amazingcharts.com/why-us/hear-what-users-say/kristina-garrido-case-study/

SECOND YEAR ANNIVERSARY!

It is our 2nd anniversary with many positive changes for the next year. Now that we are open 6 days a week (with the addition of Lisa Garcia, ARNP) there will be plenty of convenient appointments for everyone. Also, I am on the board of Ideal Medical Practices, a non-profit dedicated to saving primary care by encouraging and educating small practices about their business and latest technology. I hope to help other doctors and nurse practitioners to practice medicine without getting on the "hamster wheel."

I appreciate your continued patronage and support -- I could not have done it without you! -- KG

It’s time to collaborate—not compete—with NPs — The Journal of Family Practice

It’s time to collaborate—not compete—with NPs — The Journal of Family Practice

All the Best

Going on the second year in solo practice and very thankful for all of you -- have a wonderful, healthy holiday season!

HIPPA laws and VFC

Just so you know -- new rules are coming that will regulate email and privacy even more. It may be required that we log in to a secure server to communicate by email. This will not be free for you or me, but I do not think it will be prohibitively expensive, and may offer opportunities for virtual visits. These are the current rules on emails from Health and Human Services (HHS):

Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients?

Answer:

Yes. The Privacy Rule allows covered health care providers to communicate electronically, such as through e-mail, with their patients, provided they apply reasonable safeguards when doing so. See 45 C.F.R. § 164.530(c). For example, certain precautions may need to be taken when using e-mail to avoid unintentional disclosures, such as checking the e-mail address for accuracy before sending, or sending an e-mail alert to the patient for address confirmation prior to sending the message. Further, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail. In addition, covered entities will want to ensure that any transmission of electronic protected health information is in compliance with the HIPAA Security Rule requirements at 45 C.F.R. Part 164, Subpart C.

Note that an individual has the right under the Privacy Rule to request and have a covered health care provider communicate with him or her by alternative means or at alternative locations, if reasonable. See 45 C.F.R. § 164.522(b). For example, a health care provider should accommodate an individual’s request to receive appointment reminders via e-mail, rather than on a postcard, if e-mail is a reasonable, alternative means for that provider to communicate with the patient. By the same token, however, if the use of unencrypted e-mail is unacceptable to a patient who requests confidential communications, other means of communicating with the patient, such as by more secure electronic methods, or by mail or telephone, should be offered and accommodated.

Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual. If the provider feels the patient may not be aware of the possible risks of using unencrypted e-mail, or has concerns about potential liability, the provider can alert the patient of those risks, and let the patient decide whether to continue e-mail communications.

NPR Talk of the Nation -- About Nurse Practitioners

This is a long interview but very positive for nurse practitioners, especially those in solo practice.

http://www.npr.org/2010/11/16/131361359/role-of-nurses-in-primary-care-may-expand

Lisa had the baby!

Kelton was born on September 28 -- mom and baby are doing great and Lisa says hubby Chad is ready to do some father-son bonding and she is ready to work Fridays and Saturdays in December. Here is a little more information about your new nurse practitioner (from the website):

"Lisa Garcia graduated with her Bachelor of Science in Clinical Laboratory Science from Brigham Young University. She began a Master’s degree in Pathology at Indiana University before deciding that while she loved the things she learned working in a medical laboratory, she wanted something more. She was thrilled when she learned about Nurse Practitioners and their unique role in healthcare, and immediately began a Family Nurse Practitioner program at Seattle University. Lisa enjoys the opportunity to teach her patients and enable them to improve their health. Lisa is excited to join Kristina at Village Family Clinic. She interned with Kristina during her time as a student, and enjoys the warm and caring environment that Kristina has created. She likes the opportunity to spend time with each patient, focusing on health and wellness. She also appreciates the kindness and welcome that Kristina’s patients showed her during her internship!

Lisa and her husband Chad have lived in the Seattle area for 3 years, and love the green trees, mountains, and variety of community activities. They have one son, Kelton. In her free time, Lisa enjoys reading, spending time outdoors, and scrapbooking."

Fall at VFC

New Hours and New Provider!

This fall brings about some wonderful changes for the clinic starting with the addition of Lisa Garcia, ARNP. Many of you met Lisa while she did her internship for Seattle University’s nurse practitioner program. Well, she has now graduated and passed her boards, but she still has one more thing to do – have a baby! After she becomes a mommy, she will work Fridays and Saturdays, hopefully by the beginning of December. This means that the clinic hours are changing to:

Monday, Tuesday, Thursday and Friday – 9am to 5pm
Wednesday and Saturday – 9am to 1pm

Flu vaccine Saturdays – October 16 and November 6
The schedules are open on AppointmentQuest for children and adults. The schedules are separate because I will give the kid vaccines, and Prevention MD will provide the adult vaccines. I will charge insurances for the kid vaccines, and just like at the pharmacies and grocery stores, Prevention MD will charge $25-30 at the time of service for the adult vaccine (with a RN administering the shots). Sign up now so there will be vaccines available for everyone.

Policy Alert
Now that Michele and I have figured out the billing (as much as possible), I wanted to focus on two policies that will effect most of you.
COPAYS -- For those of you who have a copay, we are required by contract with the insurance companies to collect the copay before submitting the remainder of the bill to the insurance company. When we do not collect your copay at the time of service, we must bill the remainder after the insurance reimbursement. Honestly, it is a book-keeping hassle, and one for which we will charge a $10 administrative fee. Now I recognize that life happens and you forget your wallet or your teenager comes in without you, so our solution is sending a PayPal bill immediately after the visit. If you pay the copay within 48 hours, you will not be charged the $10 administrative fee.
DEDUCTIBLES -- For those of you who have deductibles with your insurance, I want to offer a 25% discount off the charge if you pay at the time of service. Often this will save you about $5-10, and depending on how much you come in, that may add up quickly. By law I must charge the same amount to individuals and insurance companies, but if any of those can pay on the same day, they will get the discount (no way will an insurance company pay me same day). Examples would be – if the charge for a 15 minute appointment is $100, same day payment is $75; if the charge for a 30 minute appointment is $150, same day payment is $112.50. We will still submit it to your insurance company so your get credit for the deductible. This hopefully will save you some money and it helps the clinic’s cash flow when the deductibles reset in January.

And to all of my great patients -- HAPPY AUTUMN!

This is your head on STEROIDS!

OUCH! After a night of wheezing and croup, my son got a hefty dose of steroids -- which made him crazy and he ran into the side of our chopping block.

So if I ever need to start you on steroids for inflammation, and I tell you to "use your superpowers for good" I really mean it...

KG

NPs ROCK!

Here are a couple of research studies telling you all something you probably know already... I have the best patients in the whole world!

http://news.opb.org/article/15435-survey-finds-patients-nurses-well-doctors/

http://nwhf.org/images/files/The_Nurse_in_Your_Future_-_Oregonian_-_Aschenbrener.pdf

IMP Camp 2010

On the weekend of 10/1, I traveled to Denver for an Ideal Medical Practice (IMP) conference. This is a group of forward-thinking health care providers, including doctors and nurse practitioners, who work on real solutions to preserve solo practice primary care. I presented Village Family Clinic as an example of a successful, sustainable practice, and I was elected to the Board as the nurse practitioner liaison. For more information, here is the website -- http://www.idealhealthnetwork.org/patients

The Insurance Scheme

Here is a book about what the insurance companies really do with your money.

http://www.bloomsburypress.com/books/catalog/deadly_spin_hc_816

Here is a link to what my husband does while I am at work -- and he takes care of the kids so he is entitled to some time of his own...

http://www.npr.org/templates/story/story.php?storyId=129496479

I just think it is kind of cute and wanted to share because we love NPR.

HAIRCUT!

Somebody cut his hair right down to the scalp -- he's tried it for weeks but he is a lefty and could not work the scissors until today...

Health Care Options

Great NPR radio program about independent clinics who cut out the insurance companies in an effort to maintain relationships with patients, and not the money...

http://www.npr.org/templates/story/story.php?storyId=127777327

In October, I am invited to speak at a conference in Denver and present the medical care model of Village Family Clinic. With high technology and low overhead, the clinic is sustainable and successful. I believe that this type clinic will thrive with any type of health care reform, so I want to share it with other physicians and providers. Have a great summer!

Great view from PBS Frontline

http://www.pbs.org/wgbh/pages/frontline/vaccines/view/