NNPEN’s New CEO Discusses Growing Role of NPs in Home-Based Care
About the Article: Lynn Rapsilber, DNP, co-founded the National Nurse Practitioner Entrepreneur Network (NNPEN) in 2017 to help nurse practitioners (NPs) launch sustainable businesses. And, now, she is pledging to do even more to assist her fellow NPs as the new CEO of the advocacy organization. HCCInsights talked with Rapsilber to find out her plans for NNPEN, how NPs finally have a seat at the table with insurers, and why NPs need to further develop their “business brain.”
HCCInsights: Tell us about NNPEN and your new role.
Rapsilber: NNPEN was started with the goal of educating the nurse practitioner’s “business brain” because in our standard NP education and training, we did not typically get this information.
NNPEN was the brainchild of Sandy Berkowitz, a nurse attorney, and the previous CEO. It also included Lorraine Bock, a DNP and practice owner for 20 years; Beth Chalick-Kaplan, a DNP who works for the Centers for Medicare & Medicaid Services; and myself, a DNP. I brought coding and billing experience to NNPEN.
I then took over as CEO last July because Sandy wanted to focus on value-based payments, where she could also apply her insurance background. At the same time, I would bring my nurse practitioner experience to the helm of NNPEN and be the face of the organization.
HCCInsights:Why are you so passionate about NNPEN?
Rapsilber: I got involved in the business when I was an oncology nurse and left the confines of job security at a hospital to venture into an outpatient setting. This was back in the 1980s, when outpatient practice was brand new. I also learned about CPT and ICD when figuring out the cost of delivering outpatient chemotherapy. This got me interested in negotiating with insurance companies.
Fast forward: I’m in my NP program, and nobody’s talking about how you are paid for what you do. In my last semester, I said to my professor, “Are we going to talk about CPT and ICD codes?” She said, “What’s that?” So, I asked if I could make my capstone project an article about the reimbursement process, which was published in TheNurse Practitioner journal in May 2000. This is when I started to focus more on the business part of NP practice.
At that time, it became clear to me that, as healthcare was changing and fewer physicians were going into primary care, NPs had to start taking the lead. Since 89% of graduating nurse practitioners go into primary care, we will be the primary care providers of the future. But to take on this role, we must have a business background.
HCCInsights: Why is a “business brain” important for nurse practitioners?
Rapsilber: Cultivating an NP’s “business brain” is about understanding the value you possess as an NP and the value you bring to a practice, whether it’s for yourself or if you’re working for an organization. We also need to understand how revenue flows in and out of a practice. It also helps us to understand our value, in asking for a raise or bonus, benefits increase, or if we want to start our own business.
HCCInsights: Are nurse practitioners hesitant about learning the business side?
Rapsilber: Some people think they can put a shingle out and start billing the insurance companies, and everything will be great. They, however, have no idea that there’s this whole back-end production that you must go through to get a business up and running—having a business plan; establishing your mission, vision, and values; operations, costs and marketing; and so on.
To address the need, NNPEN started a Business Development Basics Accelerator course. It’s a 12-week online program that starts with, “Are you ready to do this?” to “What do you need to get going?” to “What planning is needed to get the business developed and operationalized? The online 24-7 format also makes the course appealing for the busy NP.
HCCInsights: What feedback have you been getting from people who’ve gone through your workshops?
Rapsilber: Every single one of them has started a business. In Florida, for example, we met with one of our first NP entrepreneurs (NPEs) who took the course, and she said the information she received was invaluable. She’s now successful. She told us if she didn’t go through the program, she doesn’t think that she would have had the courage and confidence to open her own practice.
HCCInsights: What can be done to further strengthen the partnership between NPs and physicians?
Rapsilber: That relationship is improving. I believe the biggest issue is we’re trained differently: physicians are trained in the medical model of healthcare delivery—disease-focused—while NPs are trained in the nursing model, which tends to be a more holistic approach.
The way healthcare is structured now favors the medical model: you go in, are seen for one problem, and then you’re out the door. Meanwhile, NPs want to spend more time with the patient to go over all the issues and take care of as many of them as they can during the visit.
That’s where the productivity aspect of taking care of patients comes into play. NPs sometimes feel frustrated and burned out because we need to spend more time with patients. The administrators want more productivity, and there are so many patients we need to see. This creates conflict. I think that’s causing more NPs to be disenchanted with the medical model and wanting to open their own businesses or partner with NPs who already own practices.
At the same time, NPs need to do a better job of communicating who we are and what we do to our communities, legislators, and even our physician colleagues. We need to focus more attention on articulating our value proposition.
Overall, I believe there is a real synergy in working with like-minded providers, whether they’re physicians, PAs, nutritionists, physical therapists—whoever looks to take care of the patient.
HCCInsights: How has COVID changed scope of practice issues?
Rapsilber: COVID was a blessing and a curse—a curse because of the trauma it has caused so many, but it’s a blessing in a sense that all the barriers that we had for practice have been wiped away over the last 18 months.
For example, we saw NPs in Delaware get full practice authority recently and Massachusetts acquired full practice authority earlier this year.
At the same time, though, we still have work to do. It’s important insurers understand that NPs are trained in primary care, health promotion and disease prevention. If we can get to their beneficiaries early on, provide education and training, and get them to their optimum level of wellness, we’re going to prevent long-term complications from chronic diseases and reduce long-term costs.
HCCInsights: Some people don’t seem to know much about NPs and therefore are reluctant to see one. How can you overcome that obstacle?
Rapsilber: Since there are fewer physicians out there providing primary care, more practices have NPs in those roles. So, more patients will have the opportunity to see NPs in the future.
Usually, it’s because people are used to seeing a physician and don’t consider that there are other healthcare providers out there. But when they do visit an NP, they open up to the idea. One of the things we often hear from patients is, “You listen to me.” That’s one of the biggest draws for patients.
The other important thing for patients to know is NPs look to develop partnerships with them, so we will bring them back for follow-up visits, help coordinate their care, and so on.
The other key is that we try to motivate and educate our patients to better understand the disease process, their injury, or the medication they’re taking for example.
HCCInsights: In terms of the new payment models, would an organization made up of these NP-led practices be able to apply to be a DCE as a program?
Rapsilber: That’s exactly what Sandy’s been focusing on—looking at direct contracts, understanding the requirements, and making sure that we’re not excluded in the opportunity to participate. Part of the issue in a lot of the value-based programs is you must have so many patient lives to participate, and many small NP practices just don’t meet the criteria. If we can band our practice patients together to reach that number, this would give us an opportunity to participate in these programs.
NNPEN is getting seats at the table with the insurers, and they’re listening to what we’re saying. I have a feeling you’re going to hear some really good things over the next year with regards to payment and how we’re working with the insurance companies.
HCCInsights: Why do you think you’re getting that seat at the table now?
Rapsilber: NNPEN understands what the issues are, and we’re educating our NP business owners on them. We’re starting small and gradually building that momentum. We’re also getting the ear of the insurers. They see that there are not enough physicians providing primary care and conversely not enough opportunity for NPs because our practices are smaller, and that gap must be narrowed somehow.
HCCInsights: NPs are the largest-growing segment in the home-based primary care (HBPC) workforce, according to a recent study. Why do you think the HBPC field is drawing all these NPs?
Rapsilber: It’s the one-on-one contact with the patient and being in their environment. It’s a privilege to be invited into a patient’s home, and care for them in their environment.
And it helps to create that partnership with the patient and their family members. Many times you have these relationships that last forever, so in a lot of these home-based primary care practices, the nurse practitioners will take care of those patients until they pass away. It is an incredible honor to have that opportunity.
HCCInsights: Can you talk about the NNPEN and Home Centered Care Institute (HCCI) partnership?
Rapsilber: With NNPEN, we are striving to partner with like-minded, synergistic partners who put value in NP practices, what we offer patients, what we bring to patient care, and how we’re going to improve outcomes. The overall goal is keeping our patients healthy and doing it in a way that we’re cost-minded but providing the high-quality care that we’ve been trained to do.
HCCI is one of those partners. When we had initial discussions, there was just such synergy in our mission, vision, and values for patient care, that it was natural to do things together. For example, we hosted a conference together before COVID, and it was fantastic. It was very well-received, and we still hear people talk about what they’ve learned at that conference.
HCCInsights: Why do you love house calls?
Rapsilber: House calls are an opportunity to partner with patients, to meet them where they are, and be invited into their homes. I think that’s the key—being invited in. That takes a lot of trust, it also takes a lot of courage, but I think being in that house call arena, we truly develop a partnership, a friendship, sometimes that’s carried beyond anything that you can expect.
You just get so many rewards as a provider going in and providing care in a patient’s home. You get to understand where the patient’s coming from. You get to understand what type of surroundings they are in and the ways that you can impact their quality of life.
HCCInsights: Is there anything else you want to share about your vision for NNPEN?
Rapsilber: Right now, my biggest push is for people to understand the value that NNPEN brings to our members. We’re a member service organization, so we do offer those startup options for people who want to start a business, but we also create a community for NPEs who are experienced practice owners. And our goal, hopefully, is for those experienced NPEs to provide mentorship to our new NP business owners. I think that’s the value that our NP entrepreneurs bring, plus the whole concept of the value-based platform that we’re trying to push.
We also want to reduce barriers NPs might have to attaining practice ownership, such as finding a collaborating physician; getting health insurance—we have a health insurance plan for our NP entrepreneurs; getting help with credentialing and revenue cycle management; and overall consulting. There are also many times people have ideas that they want to implement for a practice, but they’re just not sure how to articulate them. With membership, you get one hour of free consulting with one of the founders, and that can be invaluable.
We also host an “Office OURS” call, which is open to the public. Every third Tuesday we have a hot topic—the last one was on contracting. It was done by our attorney, and the information that she presented was amazing. That’s available on our website for anybody who wants to view it. We just started offering CEUs for Office OURS as well. There is a lot of value with your NNPEN membership.
HCCInsights: Let’s look into the future. How is NNPEN doing in three years?
Rapsilber: We want to develop practices, and make them actionable and sustainable. We want to work with payers so they understand the nursing model of healthcare delivery is different from the medical model. Hopefully, we can get some programs together, where NPs can develop a critical mass and pool our data so that we have that opportunity to go to the insurers and say, “These are our outcomes, and this is how we’re helping to keep patients healthy and well and also doing it at cost savings because we’re preventing them from going in the hospital. We’re preventing them from having progression of chronic diseases.” We are committed to being the premier organization for NPEs.”
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