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.
Hi, Jay. Welcome to ReachMD.
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?
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
And do you have a flat fee per person and then certain amount
for a family, how does that work?
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.
So do you take third-party payers or Medicare?
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.
And how long have you operated this practice?
Almost 2 years.
Were you always been in this area or did you just move here
and start the practice?
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.
So, many of our listening audience probably doesn’t realize
that a nurse practitioner can own their own practice. Can you explain how this
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.
And is there a supervisory requirement other than prescription?
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.
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
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
And how large is your staff?
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.
And when you add staff, would you be adding a mid-level
provider or would you consider adding a physician?
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.
Can a nurse practitioner employ a physician in a practice?
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.
And how about PAs in Minnesota, can they own their own
clinics as well?
I don’t think so. I think PAs are similar across United
States where there is more supervision.
So, this model appears to be very similar to the retail
health clinics. Are you concerned that there is some competition for your
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.
Do you have hospital privileges?
How do you work for your referrals to a specialist or to the
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.
And what about for diagnostics, for x-rays, MRIs, labs?
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.
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?
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.
Right. So, you see non-insured and under-insured.
And what are some of the best benefits of not being a
third-party insurance taker?
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.
Let's talk a little bit about your background. Tell me how
you became a nurse practitioner and what your medical background is?
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.
And how did the patients feel about being treated by a nurse
practitioner, are they open to that?
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
And how do your local M.D.s feel about your practice?
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.
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
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.
Any recommendations for nurse practitioner who is thinking
about starting their own practice.
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
Where could people get more information about the Jay
It's jayclinic.com, www.jayclinic.com.
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.
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