Nurse Practitioner Membership Clinic

NURSE PRACTITIONER FAMILY HEALTH MEMBERSHIP MODEL

Medical news contains continuous reports about the impact of concierge medicine by physicians. Is there a new trend among nurse practitioners to create a similar health model. Welcome to the Clinician's Roundtable, I am Lisa D'Andrea, your host, and with me today is Jay Fotland, a family nurse practitioner who runs a family practice in Rochester, Minnesota and today we are discussing the health membership model.

LISA D'ANDREA:

Hi, Jay. Welcome to ReachMD.

JAY FOTLAND:

Thank you.

LISA D'ANDREA:

Jay, there are lots of MD Concierge or direct pay models. You have a health membership model. Can you tell us the difference between what you do and what they do?

JAY FOTLAND:

We probably offer very similar features in our model where it includes a 1-time fee for an entire year and unlimited clinic visits, which would include anything from lacerations to nail avulsions, strep throat, things like that.

LISA D'ANDREA:

And do you have a flat fee per person and then certain amount for a family, how does that work?

JAY FOTLAND:

Yes, we help people build their insurance. We take cash or check or credit card upfront and a flat fee of 75 dollars per visit. There is more cost added if they don't belong to the healthcare membership plan that I am offered for, things like lacerations, joint injections, or aspirations, things like that.

LISA D'ANDREA:

So do you take third-party payers or Medicare?

JAY FOTLAND:

We do accept 1 insurance company where I am a preferred provider and all the rest that we found have just been the paperwork, the headaches where they don't pay my bill or pay my fee then we have to resubmit things like that. So, we just decided to go to the basically a cash clinic.

LISA D'ANDREA:

And how long have you operated this practice?

JAY FOTLAND:

Almost 2 years.

LISA D'ANDREA:

Were you always been in this area or did you just move here and start the practice?

JAY FOTLAND:

I lived in Washington State for 10 years and there are nurse practitioners including that are independent from any supervision from a physician to open their own clinics and that was always something I wanted to do and I was working towards that goal when we ended up moving back to Rochester, Minnesota. So, I have always considered it and then things just kind of fell into place in the last couple of years where I could get to this point of owning my own clinic.

LISA D'ANDREA:

So, many of our listening audience probably doesn’t realize that a nurse practitioner can own their own practice. Can you explain how this works?

JAY FOTLAND:

Yeah, I was kind of surprised by the question that we can own because I didn’t think that we couldn’t do it. I know there are some states where there are more restrictions on nurse practitioners prescriptive authority or their independence. In the state of Minnesota, we require a prescriptive agreement between a physician and nurse practitioner and it's a document that stays in the physician's desk drawer and my desk drawer at my clinic. My physician is located 80 miles north of Rochester, Minnesota, but we stay in contact by telephone or computer.

LISA D'ANDREA:

And is there a supervisory requirement other than prescription?

JAY FOTLAND:

None on premises or anything like that. It's just basically a written agreement and some of the things that we do we will review chart records once a year.

LISA D'ANDREA:

And what's your relationship with your supervising physician. Do you work for him or does he work for you or is he an independent contractor?

JAY FOTLAND:

I was paying a fee for her to be my prescribing physician. At one point during startup, when you start a new clinic, then money gets tight. She said, "okay, I will just sign until things get going then we will work on payment later on." So, it's really nice to have an understanding physician that when you are starting a new business how things can be.

LISA D'ANDREA:

And how large is your staff?

JAY FOTLAND:

There is just myself and my wife right now. I had hired other medical assistants during periods when we have been busy, but we are at the stage right now when we are right at that time when we are going to have to start adding more staff because of how busy we are getting.

LISA D'ANDREA:

And when you add staff, would you be adding a mid-level provider or would you consider adding a physician?

JAY FOTLAND:

I would probably start with like an LPN, RN. I would add a nurse practitioner if they want to come in and partner with me in my clinic. My nurse practitioner friends in the Washington area have hired physicians for their clinics, but I don’t know in the time that I met that many other physicians have compete clauses where they can't have more than 1 job.

LISA D'ANDREA:

Can a nurse practitioner employ a physician in a practice?

JAY FOTLAND:

I don’t see why not, I mean we can just sign an agreement and there is whatever kind of compensation that we would agree upon.

LISA D'ANDREA:

And how about PAs in Minnesota, can they own their own clinics as well?

JAY FOTLAND:

I don’t think so. I think PAs are similar across United States where there is more supervision.

LISA D'ANDREA:

So, this model appears to be very similar to the retail health clinics. Are you concerned that there is some competition for your business?

JAY FOTLAND:

Well, the local retail ones where they have like the ones in Minnesota called Minute Clinic, those are all around the place and sometimes that helps me a little bit. Some people think that's lot cheaper to go there, but then if they are not better on treatment or have a question, they have no way of contacting that individual. Even though they say it's Minute Clinic, sometimes the waits are 2 hours long, they treat just may be 10 things or so, and some of the patients like a comebacker kind of mad because they have statements such as "well every time I ask the nurse practitioner a question, she had to look at a book to read up the answer" and I have 30 years experience in the medical field, so it's like, yes I still look at books, but I don't really scan medical journals during patient interviews.

LISA D'ANDREA:

Do you have hospital privileges?

JAY FOTLAND:

No.

LISA D'ANDREA:

How do you work for your referrals to a specialist or to the hospital?

JAY FOTLAND:

Two of the places here in Rochester have referral hotlines where they help me schedule patients that need to see a specialist, neurologist, rheumatologist, things like that.

LISA D'ANDREA:

And what about for diagnostics, for x-rays, MRIs, labs?

JAY FOTLAND:

I have an agreement with clinic I can send patients over for x-rays. Most of the time if a patient of mine is going to need more specialized imaging then I refer him to a specialist so that they can order those tests. I have a small lab, I do some clear wave tests, but I do draw blood and send samples to laboratory for just about any blood test because I don’t have a culture counter or chemistry analyser anything like that.

LISA D'ANDREA:

If you are just joining us, you are listening to the Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. I am Lisa D'Andrea and I am speaking with Jay Fotland, a family nurse practitioner, who runs a family practice in Rochester, Minnesota and we are discussing the nurse practitioner family health membership model.

So, Jay you are in the neighborhood of the Mayo Clinic. How do you compete with them?

JAY FOTLAND:

I am not in competition with the Mayo Clinic. I am not even on their radar. You are talking about millions of patients versus just a handful of patients, local patients that either don’t have insurance coverage at the Mayo Clinic or no insurance.

LISA D'ANDREA:

Right. So, you see non-insured and under-insured.

JAY FOTLAND:

Correct.

LISA D'ANDREA:

And what are some of the best benefits of not being a third-party insurance taker?

JAY FOTLAND:

It pretty much limits having any money that I am waiting for to come in from insurance companies. So, I am usually paid the same day. I have patients that can't pay the same day and they are ill and they have no place to go and I don’t turn them back. If there is patient that needs more care than I can provide here, I don’t charge for those visits and I refer them to the emergency room, urgent care, or specialist.

LISA D'ANDREA:

Let's talk a little bit about your background. Tell me how you became a nurse practitioner and what your medical background is?

JAY FOTLAND:

I was in the Air Force in 1974. They said, "okay, you are a medic," so I had the experience as a medical corpsman, worked in remote sites in Alaska and the emergency rooms in Alaska and Colorado. After graduating, I also did a program, graduated as an EMT. I returned to Wisconsin, went back to school in Minnesota to get my Bachelor of Science degree and then I started working at the Veterans Administration Hospital in Minneapolis, and in the second year, there is an RN, which said, "well you should look at this nurse practitioner program." I never heard it of before. I looked into it and I said, "well it sounds like something I could do," because I was doing many of those same tasks as a medic, suturing, reading x-rays, things like that, and then when I graduated from that program, I moved to Seattle. At one point, I was going to try to get a job in Alaska, but there was nothing up there, so then I settled in Seattle area for about 10 years and then we moved back to Minnesota in 1993, but I have always thought about opening my own clinic and after working for everybody else's sake, basically I was on a patient conveyor belt just one way or other all day long and really I didn’t have enough time to talk with patients or try to get to know them and understand their needs better, so with my own clinic, I can schedule my own time and my own hour and take the time that I need to feel comfortable managing their needs.

LISA D'ANDREA:

And how did the patients feel about being treated by a nurse practitioner, are they open to that?

JAY FOTLAND:

Lot of patients need to be educated on what a nurse practitioner can do in the state of Minnesota. I think in other states where I have the most experience with besides this was Washington State, they are more comfortable, they are more widely used, and I think just about every physician practicing in Washington State probably has a nurse practitioner one time or another.

LISA D'ANDREA:

And how do your local M.D.s feel about your practice?

JAY FOTLAND:

I think they are all supportive of it. I think everybody is kind of looking at me and saying, "well, I wonder how long he is going to last" and things like that because I think I am the first nurse practitioner in the state of Minnesota to open a Family Practice Walk-In Clinic. So, I might be more under the microscope than I know.

LISA D'ANDREA:

Let's just go back to the health membership for a minute. In the health membership, you charge the annual fee. What's included in that fee?

JAY FOTLAND:

It's any services that I can provide here. Full physical and blood tests that are age appropriate, flu vaccine, basically any minor illness or injury is covered.

LISA D'ANDREA:

Any recommendations for nurse practitioner who is thinking about starting their own practice.

JAY FOTLAND:

There are days when I think you have got to be crazy to do something like that because it's really nice just to drop your stuff on your desk and just go home where I am actually doing the janitorial work, I am ordering supplies, you know I am trying to say, "well, how can I make my desk look less messy when the patients come in to have their blood drawn," things like that, but I think you have go to do your homework. You have to have a good lawyer to make a good contract, you have to have a really good collaborator. My physician collaborator has backed me up; she understands me; she knows that I am safe; I am not sticking my neck out; if I ever had a question, I have always asked her. Since I am not a businessman, I have to have a good account in other business people that help me, saying "okay, well Jay you don’t know anything about business," and sometimes I give care away for free that's the hardest part is trying to be a good businessman and billing at appropriate levels.

LISA D'ANDREA:

Where could people get more information about the Jay Clinic?

JAY FOTLAND:

It's jayclinic.com, www.jayclinic.com.

LISA D'ANDREA:

Okay, I would like to thank my guest, Jay Fotland, for coming on the show.

I am Lisa D'Andrea and you have been listening to the Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. Please visit our website at reachmd.com, which features our entire library to on-demand podcasts and thanks for listening.

You are listening to ReachMD XM 160, The Channel for Medical Professionals. I am Dr. Larry Kaskel, please join me this week on the Clinician's Roundtable. I will be talking with Dr. Kathleen Franco, Associate Dean of Admissions and Student Affairs at the Cleveland Clinic Learner College of Medicine and will be talking about free medical schools at the Cleveland Clinic.

I am Lisa D'Andrea, join me this week when I will be speaking with Bob Blumm, President of the Association of Plastic Surgery Physician Assistants. We will be discussing surgical physician assistants employed by hospitals.

I am Dr. Ketan Sheth inviting you to tune into hot topics in allergy this week as we discuss health effects of molds, what's real and what's not, with Dr. Jay Portnoy at the University of Missouri, Kansas City School of Medicine.

Download complete program information by streaming on-demand podcasts and free CME at reachmd.com. ReachMD, Online, On-Demand, and On Air at XM 160.

You are listening to ReachMD, The Channel for Medical Professionals. This week ReachMD is moving to XM Channel 160. Please make a note and tell your associates and friends. ReachMD, The Nations Channel for Medical Professionals, will now be on XM 160 and thank you for listening.