Episode Transcript
[00:00:00] Speaker A: I'm Dr. Andrew sun and on Naked Conversations, we bring honesty back into the conversation. We talk about what's beneath the surface, the places where fear, meaning, emotion and identity intersect. Naked conversation, the Now Media Television.
Welcome to Naked Conversations with Dr. Sun, the show where we stop whispering about sex and start talking like adults with empathy, facts and zero judgment. I'm your host, Dr. Andrew sun, and tonight we're getting straight into the real world. Why sexual health concerns like erectile dysfunction, low desire, pain with intercourse, confidence issues, intimacy after divorce still get brushed off or buried after awkward silences. Joining me are two powerhouse nurse practitioners, leaders who are changing how care and practice ownership gets done. Dr. Lynn Rap Silber, co founder and CEO of National Nurse Practitioner Entrepreneur Network, and Dr. Lorraine Bach, nurse practitioner, co founder and COO of NNPEN.
Tonight we're connecting the dots between sexual wellbeing, emotional health and the front lines of healthcare where NPs often do the listening that patients can't find anywhere else. Welcome to the show and thank you so much for being here today.
[00:01:13] Speaker B: Thank you so much for having us.
[00:01:16] Speaker A: Absolutely. I'd like to start with a very open ended question for our audience. Can you just briefly tell us what is a nurse practitioner and what makes them special?
[00:01:25] Speaker B: So a nurse practitioner is a registered nurse who has gone on for additional training, either a master's degree or a doctorate in nursing, to learn advanced assessment skills, to learn how to interpret lab tests and be able to order proper testing for folks who are having problems, who can prescribe medications and deliver healthcare independent of a physician.
[00:01:53] Speaker A: Yeah, awesome. You know, I'm a urologist and I work with many nurse practitioners and physician's assistants and we could not do our practice, you know, in 2026 without the help of y'.
[00:02:04] Speaker B: All.
[00:02:04] Speaker A: Can you just comment on how things have changed? I think a lot of people are not as used to seeing nurse practitioners now before as they are now.
[00:02:13] Speaker C: Yeah, that's a great question. Our numbers are growing. We are at 461,000 nurse practitioners every for this year and it continues to grow. We're producing more and more nurse practitioners in the workforce which is helping to fill gaps in care. And a lot of them are wanting to venture out into opening up their own practices. They see needs in their communities and they want to be able to provide the care that they would like to give in the communities where they live and serve.
[00:02:43] Speaker A: Yeah, it's very interesting. And so you actually have nurse practitioners running their own practices now?
[00:02:49] Speaker B: Absolutely.
[00:02:51] Speaker A: For someone who is a nurse practitioner, how would they Venture off into that. I'm sure it can seem a little daunting at first for someone to just start off and run a new practice now, you know?
[00:03:02] Speaker B: Oh, it is daunting.
[00:03:04] Speaker A: Yeah.
[00:03:06] Speaker B: Very much so.
So one of the things that we recognize at the National Nurse Practitioner Entrepreneur Network is that in our schooling, in our education, we learn how to take care of patients in a clinical setting. We learn how to deal with their problems, their concerns, their emotional issues, what have you. But we don't learn anything about business. So at NN Penn, we have created business education for these nurse practitioners to give them support as they go through, because that's usually the biggest thing that keeps them from starting a practice is I don't know anything about business.
[00:03:41] Speaker A: Sure. I wish I had that, too. You know, in medical training, we also don't learn anything about business. And then we all grow up in sort of academic environments. Right. And then you're sort of thrust out into the real world and supposed to just figure it out.
Are there any special licensing differences between, you know, a nurse practitioner being independent, or do they still have to have physician supervision, or is it completely unnecessary? Now,
[00:04:06] Speaker C: every state has different practice authority rules. Right now, there are 27 states in the District of Columbia that allow nurse practitioners to practice independently, and some have a transition to practice where there is some agreement that has to be made with a physician in order to practice.
So those are things that we are looking to change in some states. During COVID we had two and a half years where we had waivers allowing us to be able to travel across the country to provide care where it was needed. And when the pandemic ended, all of those practice barriers were put back up. And I know a lot of states are trying to relinquish those barriers that we are able to be practicing to the top of our education and training.
[00:04:52] Speaker A: Interesting. So, you know, I'm curious if you were counseling like, say, a young nurse or a college student who thought they might want to pursue this path. They don't have to commit to being a nurse practitioner right away. Right. You would still be a nurse for first for a while and then kind of evolve into this.
[00:05:10] Speaker B: Absolutely. So for me personally, when I'm talking to young folks who want to become nurse practitioners, they have to have a bachelor's degree first before they can get into a nurse practitioner program. And I encourage them to practice anywhere from two to five years before they go to nurse practitioner school. You just have to be comfortable in your role as a nurse and what advocacy you have as a Nurse in your decision making, in your just that sixth sense that nurses have. And you need time to develop that. And I think that's critical when you start your training as a nurse practitioner to have that experience under your belt. So no, you don't go to school immediately to become a nurse practitioner. You have to become a registered nurse first. And then many programs require, require practice as an RN in some field that you have to have prior to getting admitted into a nurse practitioner program.
[00:06:03] Speaker A: Ah, interesting. Okay. Now in my experience, you know, most of the nurses I interact with are in the hospital, although there are of course many who do outpatient, you know, work as well in practices. Are there certain fields that seem to that nurse practitioners seem to gravitate towards upon achieving that designation, like certain subspecialties or in hospital versus, you know, outpatient clinics or things like that?
[00:06:27] Speaker B: Go ahead, Lynn.
[00:06:28] Speaker C: Oftentimes nurse practitioners will develop an expertise or an area, excuse me, that they would like to practice in. And that leads oftentimes to finding problems within their communities that they want to solve those problems. And that often can trigger an idea in their mind that they want to create a practice around that.
Some of the unique practices that we've helped nurse practitioners create is a primary care for a megachurch.
We've done a mobile van that helps with kids in preventing them from having mom to collect all the kids and bring them to the office and subject them to other germs. If the care can come to them directly, that helps nurse practitioners going into patients homes doing telehealth, addiction medicine, weight management. I mean, if you can think it, we can create a practice for that.
[00:07:20] Speaker A: There's so much in need as well, especially I find in the more rural settings, you know, with healthcare having changed the way it has in large cities like we're in Dallas. So many of the primary care offices are now essentially owned by large health systems and there's not that many independent practices left. There are some. Do you find there to be sort of a rural urban split in terms of, say, availability for these kinds of jobs or the ease of, you know, being a nurse practitioner entrepreneur?
[00:07:49] Speaker B: So one of the things that we really find is that nurse practitioners tend to come home to their own communities so that, you know, wherever they train, wherever they get their education, a lot of times they come back to their own communities because they know that these communities have a need for either a specialty practice or a primary care practice. And we find that a lot of nurse practitioners, about 80% of us, are trained and work in primary care. The other 20% of us work in hospital settings and specialty practices, things like that. So, you know, there is a big split. And originally, nurse practitioners, I don't know if you're familiar with Dr. Loretta Ford, but she was a home health pediatric nurse, so she went out in the community and saw patients in the community, and that's actually how the nurse practitioner role started.
She and Dr. Henry Silver created the role because she was going out and care was delayed because she couldn't make decisions and prescribe medications for patients that she was seeing in the community setting.
[00:08:52] Speaker A: That's fascinating. You know, definitely one of the powers that nurses have versus us physicians is you have generally more time, probably a better bedside manner than most of us, which I think a lot of patients would certainly appreciate.
If you're, say, a nurse practitioner and you've been in a big practice for a few years and you want to venture off on your own, how does one even get started? What kind of resources do they tap into with y' all or, you know, what would be like a roadmap for that?
[00:09:21] Speaker C: The big thing is making that push play that you want to get started. There's a lot of noise out there. A lot of people want to help nurse practitioners start their practices. So the best thing is to start asking a lot of questions. We're a network that provides thoroughbreds in our stable of partners who understand nurse practitioner practice, that it is different from the way physicians see patients, and we can help them, guide them through the process of starting their own practice, giving them that foundational skill set that they don't get in school, and then provide a community beyond that where they can get that additional support and camaraderie and community as they move forward.
This didn't exist when a lot of nurse practitioners were out there, and many have made many mistakes. And I think Lorraine can share her comments on that for sure.
[00:10:12] Speaker B: Yeah. I ended up starting my practice because the physician that I was working with needed to retire for health reasons. He needed to get out of the business for health reasons. And we had about 10,000 patients in our practice and someone needed to take over. I knew nothing about business. And I can tell you that I have made just about every possible business mistake that you could make. And so when Lynn and myself and our third partner, Sandy Berkowitz, got together, we decided that one of the things we wanted to do was provide the background for these nurse practitioners so that when they took the leap into independent practice, they had experienced folks to draw from, so they didn't make all the Same mistakes that we did.
[00:10:55] Speaker A: Yes. You almost necessarily have to make some mistakes in the beginning when you're going at such an endeavor. But that's awesome that you guys have built this network and are able to help young nurses and nurse practitioners kind of evolve into this modern practice.
So we'll come back after the break and start getting into the nitty gritty of some clinical information. But thank you so much for this wonderful introduction.
Welcome back. We talk a lot about sexual wellness, but access is the part that nobody puts on the brochure.
If a patient has to wait months, travel too far, or feels judged by the second they bring up sex, they simply won't come back. And that's where nurse practitioner leadership or policy changes become personal.
So I wanted to delve into how a nurse practitioner would set up a sexual health practice, either as an arm of their existing practice or as their, you know, main focus.
If, let's say you had a nurse practitioner who wanted to make this kind of kind of field, sexual medicine, a focus for them, how would they go about that?
[00:12:19] Speaker B: I think the first thing they need to do is really research what's out in their community and what's available to them. Because you don't want to start adding a service to your practice or starting a practice if there's already practices in the community that meet that need. So the first thing you want to do is look at your ecosystem that's around you. Is there other practices that way? And then the second thing is to make sure that you have the background and the support to do that.
A lot of times, we'll try and fill a need in our community, and it will require us to get a little bit of extra education. And I think before you start a specialty practice, particularly in sexual health, you need to make sure that you, as the provider, have a strong background and education and feel comfortable talking about it. You know, knowing your own biases when it comes to talking about something like sexual health is incredibly important. You know, if you're uncomfortable talking about it or you've had a traumatic experience with sexual health, it's going to color the way that you deal with your patients. And you have to be aware of your own biases and your own limitations.
[00:13:24] Speaker A: Absolutely. I couldn't agree more. You know, we in the sexual medicine community, we have a lot of nurse practitioners that are part of our practices or run independent practices. We have a large academic body called the Sexual Medicine Society of North America. And there are a tremendous amount of resources specifically directed at nurse practitioners and physician assistants to Help them learn both the science and much of the art of sexual medicine, because it's very much a specialized area and you kind of have to be very comfortable and have a certain personality when talking about these things. Like you said, if you feel uncomfortable, the patients will immediately feel uncomfortable.
But that is one thing that I think nurse practitioners probably in general would excel at. And there's a tremendous need in this space.
So let's say you have an idea and you have the education and you want to venture out.
What kind of community referral networks or relationships would you recommend they go about building, or how would you start on that part?
[00:14:20] Speaker B: Well, the first thing I would have them do is do a business plan, an actual official business plan to look at what services do you think you're capable of offering. Do you want to bring any of these specialists, like therapists or physical therapy or mental health or, you know, anything like that? Do you want to bring that into your practice, or do you want to build a referral network outside your practice to do that? And then really start to look at, what am I going to need to set this practice up? Am I going to need office space? Is it going to be able to be telemedicine? Do I need to have, you know, what equipment do I need to have? So that when you're ready to open the doors, you have all the things in place that you need. And some of these decisions will be easy, and some of them will be very hard. You know, sometimes it's hard to find a specialist in physical therapy for pelvic floor or mental health therapy, someone who's easy, you know, comfortable talking. It's easy for them to talk about sexual health. So looking around and seeing what's in, excuse me, what's in your community? And then how do you want to build your relationships with them as you build your practice up, do you think,
[00:15:27] Speaker A: you know, in going about setting this up, you know, sometimes there are like, shall we call them turf wars or things that you can kind of tread on people's toes about. Is there a way to help negotiate that, say, with physicians in the community, or is, you know,
[00:15:43] Speaker C: that's a great question. And certainly there's been opportunities for nurse practitioners primarily, who want to do the GYN aspect and the sexual health aspect of a practice, can partner with a physician group, but that doesn't want that. And they can share the patient referrals back and forth. I think that's one way that we could help each other and our practices grow. If that independent NP practice owner who's doing, doing the GYN exams and can be that referral source. I think that would be a nice way to partner
[00:16:16] Speaker B: with.
[00:16:19] Speaker A: Yeah. You know, so in our practice we have about 30 doctors and 17 either nurse practitioners or physician assistants. And the medical sexual health side of it is essentially completely run by the nurse practitioners and physician assistants.
They see most of the patients, they do all the procedures. You know, hormone replacement has become a big thing these days and I think that is a very common thing. Let's chat about that real quick. What do you do? You see, I don't know if you have any population data about the prevalence of hormone replacement type services offered by nurse practitioners. It seems to be fairly common, but that's maybe just my insight on
[00:16:58] Speaker C: is a growing area.
[00:17:00] Speaker B: I don't have any actual data on that, but I can tell you that in my experience in 30 years as a nurse practitioner, that got turfed to me in every practice that I was in.
It takes a long time to educate people on hormone therapy and it takes a long time to get the right balance of medication with patients. And a lot of times, at least the physicians that I work with, you know, they didn't really feel comfortable spending that much time in a visit. So all of the preparation for that flushing out what symptoms you're trying to, you know, address with the hormone therapy and what have you always felt to me and the pelvic exams and what have you. A lot of times the female patients always wanted a woman to do that.
[00:17:44] Speaker A: Yes.
[00:17:45] Speaker B: And so I think, you know, just naturally that comes to us because we're women.
[00:17:50] Speaker C: And I think the other point to bring up is that we do focus on whole person care.
So with a lot of sexual health comes a lot of other sleep disturbances and other hierarchy of needs requirements that we can address with our patients. And that does take time for us to do, but we're trained to do that.
[00:18:11] Speaker A: Yeah, absolutely.
So when you're doing that kind of multi centered care, then you have referral relationships with like sleep medicine, either doctors or NPs as well, and sexual counselors, psychiatrists, all that kind of stuff.
[00:18:26] Speaker B: Absolutely. You know, one of the things I think that nurse practitioners have learned to do very well is build networks of referrals and colleagues that they can pick up the phone and say, hey, I have this. You know, do you want to. Do you think I should come to you? Is it something you think that I can manage here? But you know, knowing what physical therapy, I mean, pelvic floor therapy is huge for women, knowing that there's a physical therapist in your community that can do that, knowing that there's a counselor, knowing that there's a psychiatrist, if you need to prescribe medications that are beyond the scope of, you know, your practice individually.
Not only that, but there's a lot of other issues that can go in. Like you said, sleep medicine. People who are having sleep apnea, who are not getting good sleep, can have sexual dysfunction just based on the fact that they, they're so sleep deprived. Not to mention hypertension and diabetes, which can have a significant impact on sexual performance and libido. And if you're, you know, if it's something that you can't manage in your practice, in your sexual health practice, you need to have the network of specialists to be able to refer out to get that hypertension under control or to get that diabetes under control. But I think the whole person care that nurse practitioners bring to the table can help identify that. When the people come in and they, you know, I have erectile dysfunction and no one's looked at their metabolic profile and all of a sudden you find out that their blood sugar's been, you know, 280 for the last three years and it's never been treated. No wonder they have erectile dysfunction or they have untreated hypertension or they have, you know, some other medical issue.
Prostate enlargement for men can be a huge issue.
[00:20:06] Speaker A: And that's one of the things that we always comment on, is that as a sexual health specialist, a lot of times you're actually serving as a version of a primary care doctor for the patient, especially for the men, because, let's face it, men are not very good at going to the doctor. And so sometimes, as you said, the reasons that men get erectile dysfunction are the same reasons they get heart attacks. It's diabetes, high cholesterol, high blood pressure. And sometimes it's that person talking about their sexual health that's going to unearth those things and make a profound impact on this person's life, not just in their sexual health. From a hormone standpoint, as you mentioned, it's definitely seeming to become very popular.
I think a lot of the flawed, shall we say, studies over the many decades prior have been overturned. And so I think it's definitely exploding.
As you said, women definitely, I think, are more comfortable seeing women, although, of course, not every nurse practitioner is a woman.
Do you know what percentage of nurse practitioners are men?
[00:21:05] Speaker C: I'm not 100% sure on that answer, but I do know that there are a lot more men entering the field for sure. And I think that's really a positive thing for our profession is to have more males so that patients can identify with a male nurse practitioner taking care of them.
[00:21:24] Speaker A: Yeah, I totally agree.
You know, when a nurse practitioner is starting out like this, where do you think they're most commonly either underselling themselves or overextending themselves or the common pitfalls that they might encounter?
[00:21:40] Speaker B: I think one of the hardest things is feeling comfortable making the leap from a full time position where you have benefits and vacation time and disability and what have you. It's very hard to, to make that leap into practice. So a lot of them start out with a part time, what we call a side hustle, where they're keeping their full time job and they're working the side hustle. And I think one of the pitfalls is they don't really have a good sense of when am I busy enough to make the leap from a regular full time position, being employed from someone else into my own practice. And if I do, how do I get those things that I need, like healthcare benefits and what have you? And that's where something like the National Nurse Practitioner Entrepreneur Network can help. We've made partnerships with benefits companies that will offer benefits at a more reasonable rate than say some of the big insurers. For people who are self employed, we can help them get benefits for their employees.
And I think that's one of the biggest hardships for folks is just figuring out how do I make this work so that I get what I need and I'm not overwhelmed? You know, sometimes if you're doing it as a side hustle, you're doing it on evenings and weekends. So you're working all day and then you're coming home and you're going to the office for two or three hours in the evening. And you really have to balance your own self care as well.
[00:23:02] Speaker A: Yeah. And under making that journey. This is a large question, but what do you think success looks like? Like, how do you know you've done it? You know, is it, is it outcomes, personal satisfaction, schedule control? Like, what does good look like to you?
[00:23:16] Speaker B: So sometimes it's getting flowers. Like I just literally got flowers from a patient that I took care of today I went into work and I got flowers from a patient and a little note that said thank you so much for caring so much about me. It was obvious that, you know, you were worried about me and not about all the other people that were around you or that you were taken care of. And for me, for me personally that's part of success, obviously, being able to pay the bills, being able to grow your practice, that's all success, too. But most nurse practitioners, for us, it's that satisfaction that we've really made a difference in someone's life and we've addressed a need that they felt couldn't be addressed by other practitioners or that they wanted to talk about for a long time.
[00:24:05] Speaker A: I think that's fantastic and a great way to end this segment. Thanks so much. And we'll be back soon to talk more about the nitty gritty of practice, coding, documentation, things that you really got to watch out for to make sure that you do achieve that success that you just described.
[00:24:30] Speaker C: Foreign.
[00:24:40] Speaker A: Welcome Back to Naked Conversations. We're here again with Dr. Lynn Rapsilber and Dr. Lorraine Bach from NN Penn. And now we want to get into some more of the nitty gritty of the practice of medicine. As a nurse practitioner, I only know the doctor's perspective. Can you guys comment, comment on some of the differences in scope of practice or the way that practice works As a nurse practitioner, independent practice versus a conventional physician's practice.
[00:25:06] Speaker C: As far as nurse practitioners, we're licensed as independent practitioners, but we have regulatory barriers. Each state has their own rules by which we have to practice, and a lot of them force us to be in collaborative arrangements with physicians.
And with that, it provides difficulty sometimes because we know the pool of physicians are decreasing.
And nurse practitioners, if they have to find a collaborating physician, sometimes have to pay for that privilege.
And if they don't have a collaborating physician on board and they lose that ability by the regulations, they have to close their practice. They cannot operate. So if you don't have that collaborative arrangement already set or a backup in case something happens, those patients no longer have access to care. And that is a huge problem.
Not to mention that it prevents good quality educators from being trained in states that have these regulatory rules as well. So there's a lot of concern with the practice authority. And during COVID we had two and a half years where we had our waivers relinquished so that we could go and practice where we needed to be. And now to put those regulatory barriers back up, it's really affecting the access that patients have to care.
[00:26:28] Speaker A: Oh, wow. So in those two years you had people set up practices, but then they reinstituted more barriers after the fact now.
[00:26:36] Speaker C: Right.
[00:26:37] Speaker A: Wow.
[00:26:37] Speaker C: Right. So an example. I'll give you a good example. In New Jersey, the governor Murphy, when he was in office, signed an executive order allowing those nurse practitioners for independent practice. They had it for six years. He's now out of office, and so his executive order is no longer valid. So now they're scrambling to try to get legislation passed so that they could have full practice authority. And, you know, again, this is a situation where six years they were fine, and now all of a sudden, we have to put barriers up.
[00:27:09] Speaker A: You know, if there was. If you had the power of the pen and there was one policy change you could make, or multiple ones to improve access to care and improve the autonomy of nurse practitioners, what would your laundry list be?
[00:27:22] Speaker B: I think getting full practice authority in every state across the country would be good. You know, and there's a big misconception that when nurse practitioners get full practice authority, that they stop collaborating with other healthcare professionals and that we do things that are outside of our scope of practice or outside of our education and training. And that's not true. Nurse practitioners don't collaborate with healthcare providers outside of nursing because they're told to by a piece of paper or by some statute or regulation. We do it because it's what's best for our patients. And having that need to have a collaborating physician or a supervising physician, depending on what state you're in, can be very difficult.
In Pennsylvania, we have to have actually two collaborating physicians, and it's hard enough to get one, let alone have to have two, and to have to pay money.
A lot of times physicians can't collaborate with nurse practitioners even though they want to, because they work with big health systems, and those health systems have constraints on what they're allowed to do. And if the nurse practitioner isn't in the health system, which if you're having your own independent practice, you're not in a health system, then those physicians can't collaborate with you. Or the fees are very expensive. I had a colleague who paid her collaborating physician nearly $5,000 a month. He was a psychiatrist, she was a psychiatric nurse practitioner, and she had overhead right off the bat of five grand a month to pay the collaborating physician.
That's terrible. In other states, the collaborating physicians has to live within a certain distance from the nurse practitioner practice, and it can be very difficult. So, you know, that would be the first thing that I would remove, is the mandatory collaboration or supervision. The second thing I would do is I would say that instead of giving insurance companies the option of whether or not they're going to contract with nurse practitioners, that I would make it mandatory that if they contract with physicians in that specialty or care area, that they also had to contract with nurse practitioners that would Remove two huge barriers to allowing nurse practitioners to be successful. And I don't know, Lynn, do you have anything else on your wish list?
[00:29:31] Speaker C: Oh, getting rid of that 85% reimbursement rate.
That's huge. That too, again, you know, that 15% deficit. Yet we still have to, you know, pay the same amount of money for supplies, insurance, et cetera. It can be, you know, again, a daunting task for a nurse practitioner to take on practice ownership when they're already at a deficit in so many of these areas
[00:29:54] Speaker B: and the margins are so small. I mean, in any practice, whether it's a specialty practice, a primary care practice, the margins are so small for being successful financially that that 15% actually is huge to make a difference in whether you can stay open or not. You know, we can't pay our medical assistance 85% of the rate for a medical assistant in our area. They don't want to work for us. We can't pay 85% of our light bill, but yet we're expected to function with 85% of reimbursement. That's already low in most cases for what we do. You know, insurance companies don't pay providers the going rate because it's a fair rate. They pay it because it allows the insurance companies to be profitable.
[00:30:39] Speaker A: Yeah, certainly seems I always think about the barriers of a different, of starting independent practice these days as a physician, but you guys have to deal with all of those things as well. But I can imagine the rewards of independent ownership, autonomy, freedom to practice the way that you want, your relationships with patients. It's certainly well worth it, especially with your help in terms of the network that you can provide to help nurses practitioners get off the ground.
What would you say?
[00:31:04] Speaker B: Absolutely.
[00:31:04] Speaker A: Yeah.
[00:31:05] Speaker B: Most nurse practitioners leave corporate healthcare because they cannot take care of patients the way that they were trained to take care of patients. They're jammed into 8 minute visits or 15 minute visits and they really can't address things. They become very morally injured because they can't deal with the problems that the patients want to deal with because they're forced by their employer to see a certain number of patients a day or to bill a certain number of visits a week or what have you. When you go into independent practice, particularly if you go into a cash based model, you can structure your practice the way that you want to, and if you become an expert in billing and coding, you can bill insurances and really get the maximum reimbursement for everything that you're doing.
[00:31:49] Speaker C: Plus there's a lot of different codes that nurse practitioners can bill that can enhance the opportunities to provide additional revenue. And that's one of the things that will help keep that cash flow going. Chronic care management, for example, is one. Remote patient monitoring is another. These are enhancements that we can participate in with our patients to give them really good quality care and, you know, have some money stream coming in to support us as well. And then side hustles incorporating some of the cash pay opportunities in addition to the insurance related opportunities communities as well.
[00:32:28] Speaker A: You know, one thing that I think most patients don't know is that the Medicare reimbursement rates have essentially been static, if not less, over the last 30 years, despite inflation, despite all the costs going up and everything.
Lots of different political arguments we could have about that, but it's certainly a big headwind that all clinicians face. That's part of the reason why there's so much consolidation, you know, with major health systems and whatnot. But when you're starting your own practice, like you said with the cash pay business, that's definitely a beneficial thing. Are there other ancillary services that you can provide like lab testing or, you know, different things like that?
[00:33:05] Speaker B: So absolutely, there are many things that we can provide.
We can do, you know, lab testing in the office. Of course, you have to have a CLIA license, which costs money, so you have to make sure that your volume offsets the that amount.
We can do flu shot clinics where we can do cash flu shots. We can do physicals for driver's licenses or truck drivers. You can get a bunch of different certifications.
The one thing I will say about reimbursement is healthcare is the only field that I'm aware of where the person delivering the service and the person receiving the service have absolutely no, no say in what that service is worth. It's decided by a third party insurance company who never sets foot in your office. And you know, imagine if you went to get your car fixed and an outside person said, okay, your brake job is only going to be worth, you know, $75 and it costs you $74 to buy the supplies. Like that's where we sit in health care is we have no set in how much we get paid when you take insurance, because the insurance company decides what that service is worth and sometimes they're under bidding. I mean, there are vaccines that I give in my office, where I'm not even reimbursed the same cost that it costs me to purchase the vaccine from the insurance company. They actually reimburse me less than the vaccine costs, and then you can't give services. And then patients are marginalized because they can't get things that they need because the practice can't afford to deliver them.
[00:34:39] Speaker C: And that's why the network becomes such a value. Because if we can align ourselves collectively and have a bigger presence with increased number of practices represented by larger volumes of patients that we serve, you know, we can start to collect data that show that we're reducing overall costs of care as a group, and then maybe go back to some of these insurers and renegotiate those contracts. We can have better buying power as a collective with supplies and manufacturers. So there's opportunities if that leverage does happen. So I encourage folks to sign up for the directory so that we can start creating that aggregation.
[00:35:21] Speaker A: And so from your perspective, how does full independent practice authority change what the patients can actually access, especially in sensitive areas like sexual health or really any field of medicine?
[00:35:34] Speaker B: Just, just having the nurse practitioner be able to open a practice without having to jump through the hoops of trying to have a collaborative physician or two collaborative physicians is really important. If you have to find that collaborative physician and you have to pay them, you may not be able to keep practice open. It happened to me last year at this time. I had the same collaborating physician for almost 17 years.
He was in his late 70s. He wanted to retire from practice and, you know, be in retirement, but didn't for almost four years because he knew how hard it would be for me to find another collaborating physician.
So, you know, there's a barrier there that if he would have retired and I wouldn't have been blessed enough to find another physician who I could afford to pay to collaborate with me, I would have had to close my practice and my patients would have lost access to care. So that's a huge thing when you're talking about independent practice. If I had an independent license, I could have kept that practice open without worrying about that.
[00:36:40] Speaker A: And then my final question is from the patient's perspective. You know, I think a lot of times there are still a lot of myths, a lot of misconceptions about what exactly a nurse practitioner is.
If you were talking to a patient, what would you say would be the biggest things that you would want them to know about what being a nurse practitioner really is?
[00:36:58] Speaker C: Nurse practitioners provide whole person care. So we don't just look at the patient as a diagnosis. We look at them as an individual that's experiencing a condition, a disease and event.
So, and then we look at to partner with our patients. To get them to their optimum level of wellness. And we take into account, can you afford the medication, you know, can you afford food, what's your housing situation like? And we're trying to make sure that we're addressing all the needs of that patient so that they could have the best possible outcome with their health.
[00:37:30] Speaker B: And, and I always tell people, you know, when people say, what's the difference between you and and a doctor? What's the difference difference between you and a physician? And I can break it down pretty simply. And it's based on the philosophical educational model. Physicians are trained to treat the diseases that people have. They learn their education through going through cardiology and nephrology and pulmonology or whatever.
So they're, you know, they learn based on a disease process. Nurse practitioners are trained to treat people who have diseases because we learn to take care of the whole person.
[00:38:17] Speaker A: Welcome back. We're in our final segment with Dr. Lynn Rapsilber and Dr. Lorraine Bach of NN Penn. And this is where the rubber meets the road. How do you build care models that respect the patient protection, protect the clinician, and stay financially sustainable, especially when the topic is sex, intimacy, emotional health, and things like that? So my question to you all to start with is for NP practice owners, what kind of systems, whether it's templates, staff workflows, things like that, you know, operate most efficiently and help protect the clinician and improve the patient experience?
[00:38:51] Speaker B: That is a loaded question, for sure. I would say one of the things that helps to definitely improve the patient experience, especially in something as sensitive as this is an AI scribe. And you might say, well, what do you mean an AI scribe? And that's really, you know, listening to what the conversation is so that the clinician isn't sitting there typing into the computer the whole time, trying to catch the conversation. The AI scribe listens to the conversation and then puts it into a format where you can just pick and choose out the things that are critical. It saves a lot of time and documentation, and it really captures the spirit of the conversation that's going on, improves your workflow, and it also helps with the coding because you can look at the elements that you've discussed.
[00:39:37] Speaker C: I would also add that I would make sure that the patient is giving you permission to utilize that AI scribe technology first. I like to always tell my patients that it helps me be a better documentary of our conversations and that I will edit out anything that they do not want listed in there because it is their personal health information.
[00:40:01] Speaker A: I think that's very important. We also utilize AI scribes. And it's truly life changing to be able to actually look at the patient in the eye and talk without having to stare at the computer the entire time. But I also agree with, you know, sometimes, especially in this field, we're talking about pretty personal stuff. And so do you always kind of tell them at the beginning like, hey, like, you know, feel free to talk about anything and I'll just not include this stuff or how do you kind of broach that topic?
[00:40:26] Speaker B: So where I practice in Pennsylvania, you actually have to get them to give you verbal permission in order to record the conversation. Otherwise it's considered a federal wiretap violation.
So you don't want to do any of that. You don't, I don't want the feds coming. So I always just say to the patient, you know, this is an AI scribe, it's going to listen to our conversation. I will edit out anything that I feel is sensitive, but it allows me to pay attention to you and it allows me to talk directly to you without having to worry about the fact that I need to catch some things for my documentation and my billing and coding later. Do I have your consent? And that's pretty simple. And I literally have never had a patient sitting say no yet.
[00:41:08] Speaker A: That's great advice. When you're doing these visits, they can be pretty long, they can be pretty complex when patients bring multiple questions and layers and layers of questions. Stress, medication management, their sleep, their relationship, how do you eat? Well, one, how do you sort of keep the bounds of what you're going to accomplish in that visit? And then two, do you advise that most nurse practitioners code based on time or complexity?
[00:41:32] Speaker C: Or again, it depends on the conversation that you're having with the patient. You want to make sure that you give them the freedom to express the issues of their concern at that visit.
Oftentimes time may be the deciding factor depending on the conversation that you're having. And oftentimes in sensitive conversations, you don't really want to cut the patient off if they're developing that rapport with you and wanting to have that continued conversation. I do think that looking at whether you decode by medical complexity or time really depends on how much work you're doing with the patient. If you're gathering a lot of information and doing more of a conversation, then time may be the way that you'll value that visit. Where if you're looking at data and information, then maybe medical decision making is the key. One of the things with documentation is that it has to be complete and there can't be any disconnects. And one thing that I've seen in chart audits is that especially when it comes to sensitive information like this, the patient may say the reason for the visit is a urinary tract. They think they have a urinary tract infection, but really when they get into the room with you, that's not the reason for the visit. It may be that they want to be tested for sexually transmitted infection. So you never know. And that has to be clarified in your documentation, the reason for the visit.
And again, any of the testing that you're doing, make sure that there's a medical reason for doing that test. Make sure that you are documenting the reason for the test. And if you're ordering a medication, why you're ordering and prescribing that medication. So your bulk of your documentation really is going to focus on your assessment and plan. And that's where the detail needs to come in.
[00:43:17] Speaker B: And to your point about how do you decide, you know, how do you start the conversation? When I'm dealing with something that's very complex or intimate, I always start every, you know, the visit, the relationship, by saying, you know, this is something that's going to take us time and we're not going to get to finish everything in one visit. It's going to take a number of visits for us to unpack how you got here, what the, you know, what we need to do to figure out what's going on and then what the plan is to start to address whatever problem it is that you're having so that you have very realistic expectations from the beginning. And just say, today we have an hour, because it's the first visit and I'd like to get through these things. But what's important to you? What do you want to get to today? Because what's important to the patient?
I may have no idea.
I may think that this is really important to get out. And the patient doesn't really care about this problem. What they really want to talk about is that problem. So spending the first five minutes of the visit, particularly on issues of sexual health, asking them, what is it that you want to address? What is it that's bothering you, I think is really important. And then setting very realistic goals for how much you can accomplish in one visit versus a series of visits over time,
[00:44:38] Speaker A: sometimes that can be a struggle for sure. But we do have to always kind of remember what we can accomplish in one visit. And oftentimes, as you said, these are multi visit you know, symptoms to address.
Are there any specific coding nuances that are, that are specific to nurse practitioners or is it essentially the same rules that physicians follow? Any different modifiers or things you have to be aware of or common traps?
[00:45:03] Speaker C: One of the things I stress is that nurse practitioners document very well, but we undercoat our visits and that tends to be a flaw that we participate in. But one of the things that I encourage folks to do is really look at what they're providing for the services. What ICD codes are complementary to the service that you're providing. And if you're providing a service and there's additional comorbid codes, such as diabetes, for example, and sexual health, put that in as an additional diagnosis code because you're going to address that as part of your sexual assessment. Same with hypertension. If you're doing something about it, then you can definitely put that in as a problem that you're assessing. The way the coding happens now is by problems addressed, data that's analyzed and risk to the patient. So if you're prescribing medications, for example, you can't just put in the chart that you're ordering an antibiotic. You have to really spell out that I'm ordering this particular antibiotic for this particular reason.
And then any follow up information that you want the patient to be aware of when they need to come back and see you, or if there's any follow up information, if you're making referrals to other providers that all needs to be clearly documented in the medical record.
[00:46:20] Speaker A: Yeah, it is very complex and there's definitely a lot of pitfalls.
You think there what would you say were the most common documentation mistakes that would trigger either denials or non payments from insurance? Always an interesting journey to have to deal with the documentation and all the nuances therein. What would you say are the most common mistakes that trust trigger denials for sexual health related visits?
[00:46:45] Speaker C: The biggest reasons for denials are that the medical necessity is not met. So your cpt, the what you do and the ICD is the why you do it are not matching up for whatever reason. So really take the time to look at the codes that you have. The other thing is making sure your documentation clearly supports the level of service that you're billing. So if you are using moderate medical decision making billable, you have to make sure that your problems are being addressed. And I would always tell people, when you're putting a problem down, make sure that you put a qualifier after it. Is it acute, is it chronic, is it stable? Or unstable, Is it an exacerbation of progression or side effect?
Those are key things to add in because that really tells the story of what's going on with the patient. And that's really what you're doing. Documentation wants to do. It wants to tell the story of what you're providing for that patient. And then that equates to the billables that go in. But the disconnect oftentimes is the CPT and ICDs are not in alignment.
[00:47:47] Speaker B: And I would say, you know, having a tickler for yourself of what you know, whether it's a template or whether it's just something that you have in front of you to remind you to do all those things, because when you're in the visit, you're trying to focus on the patient, you're not trying to think, oh, I forgot to put that it's a chronic problem, or I forgot to put that this is an exacerbation. So just having a template or some sort of tickler in your workflow that reminds you that, oh, did I put this? Did I not put that? And that can be done in AI scribes. It can be done very easily.
It can also be just a piece of paper that you use when you're ready to finish up your note to make sure you have everything there.
[00:48:30] Speaker C: All of those things end up to be time savers and make you a lot more efficient if you can set those templates up ahead of time and really utilize that. Because the other thing too is that it's coaching you to make sure that you're not missing points of documentation that you need for a particular level of service that you want to build.
[00:48:49] Speaker A: Now, for a nurse practitioner who's starting their own practice, do you have to go individually negotiate contracts with insurance companies, or are there easy ways to get that process done?
[00:49:00] Speaker B: So, unfortunately, new practices have a very difficult time negotiating.
Most of the time you just have to accept the contract that the insurance company offers you. There's not a lot of room for negotiation.
Now, if you're going into a community where there's a very high need for a very specific kind of service, sometimes you can have the ability to negotiate your rates, but most of the time it's very, very difficult. And that's one of the other things that we try to do at the National Nurse Practitioner Entrepreneur Network is we're trying to aggregate practices so that we do have some power, because an N of 1:1 doesn't have any power to negotiate. But if you are something like a big health network, Like Kaiser Permanente or something like that. And you've got thousands of practitioners and thousands and thousands of patient lives. You have a lot more power to negotiate. So in the beginning, you really can't do that unless you're offering something that's really specialized and really needed in a community. You most of the time just have to take what the insurance company offers offers you. And that's very unfortunate because most of the time we are providing care that patients find to be incredibly valuable that improves their health and overall improves the health of the community that they live in.
[00:50:23] Speaker C: The other thing too to point out is that Medicare pays us 85% of the physician fee schedule. So we're already starting practices at a deficit of 15% when we still have to pay the lights, heats, electricity, all of the functions that most other practice owners have to bear, but we have to absorb that 15% loss.
[00:50:46] Speaker A: Now in your network, I'm sure there are people who hear that and say, you know, maybe I'll just do cash only practice. Is that a common thing? Do you see that a lot? What kind of advice would you have for somebody who wants to go that route?
[00:50:57] Speaker B: Well, it's becoming incredibly more common. A lot of nurse practitioners are opting out of the insurance based practice. First of all, not all insurances recognize, credential and contract with nurse practitioners. So sometimes you can't even get in the network.
So you have to offer a cash based practice. But I think it is becoming more common and subscription model practices are also becoming more common. I call it direct cat care rather than concierge care because concierge care has the connotation of being elitist and what have you. Most nurse practitioner practices, we are catering to the people who don't have insurance, who are underinsured, people who own their own businesses, people like waitresses and hairdressers. And we create a monthly fee that they can pay, which gives you a great basis for knowing how much you're going to bring in each month. You can actually do some budgeting if you just do a fee for service. Cash business, it's really hard when you start out to budget because you don't know how many people are coming in each month.
The other thing that happens with a subscription based practice is you don't become dependent on bringing your patients in when they're sick to get them to pay you for the visit. You can actually bring them in for wellness visits and really begin to focus on the wellness and model and the value that you're bringing to it rather than you know they only come in when they're sick. So I have to have them come back two weeks after I do the antibiotic to make sure that they're well.
Or I can't do a telemedicine visit because it doesn't pay as much.
[00:52:33] Speaker A: Yeah, it's incredibly useful information, I'm sure for any nurse, nurse practitioner or patients out there for to learn from today. If anybody wants to contact you, how is the best way that either viewers or clinicians can connect with you and the National Nurse Practitioner entrepreneur network?
[00:52:50] Speaker C: There's two ways. One is www.nnpen.org. that is to our national Nurse Practitioner Entrepreneur website where we have a wealth of resources that they can peruse. The other is our directory. We have a destination np501c3ar www and that is a platform where an NP can put in their NPI number. It populates their information. They can put their NPI for their business and then they get a Google pinpoint and it's searchable for patients to find NP LED care. NPs can find each other for collaboration, for referrals and students can find preceptors because we know a lot of nurse practitioners students want to get trained with nurse practitioner practice owners. So we provide that opportunity as well.
[00:53:41] Speaker A: It's amazing. Tonight we proved something simple. Talking about sexuality is talking about health, physical, emotional and relational. If you're a viewer, you deserve answers without shame. If you're a clinician, you deserve tools and systems that let you do this work. Well, a huge thank you to Dr. Lynn Rapsilber and Dr. Lorraine Bach of NN, Pennsylvania for bringing both the clinical truth and the business reality to the table. I'm Dr. Andrew sun and this is Naked Conversations with Dr. Sun. Let's keep it honest. Let's keep it human. We'll see you next time.
