ORIGINAL RESEARCH
Decreasing barriers for nurse practitioner social entrepreneurship Dayle B. Sharp, PhD, MSN, McPH, FNP-BC (Clinical Assistant Professor) & Diane Monsivais, PhD, CNE, CRRN (Assistant Professor) School of Nursing, University of Texas at El Paso, El Paso, Texas
Keywords Nurse practitioners; entrepreneurship; rural; underserved. Correspondence Dayle B. Sharp, PhD, MSN, McPH, FNP-BC, School of Nursing, University of Texas at El Paso, El Paso, TX 79968. Tel: 915-747-5315; Fax: 915-747-7207; E-mail: [email protected] Received: 3 December 2013; accepted: 4 March 2014 doi: 10.1002/2327-6924.12126 Disclosure The authors report no competing interests.
Abstract Purpose: To describe difficulties associated with the business-related aspects of practice in role transition of rural nurse practitioners (NPs), and to give practice implications. Data sources: This focused ethnographic study derived data from semistructured interviews. Participants provided information about rural NP practice ownership and barriers. The sample consisted of 24 rural NPs living throughout the United States. The majority were 51–60 years of age (45%) and females (93%) who had been in rural practice for 1 to over 20 years. Conclusions: NP social entrepreneurs experience difficulties related to scope of practice, business skills, and role conflict. Implications for practice: To decrease barriers for NP clinic ownership and management, NPs need to receive education related to financing a rural practice, legal/regulatory practices, strategic planning, leadership, and clinic management.
Introduction/background “You never realize how much business you were not taught . . . ” (Study Participant)
As a result of the Affordable Care Act (ACA), millions of Americans will have health insurance for the first time. This important step toward reducing health disparities addresses coverage, one of the critical components of Healthy People 2020 (U.S. Department of Health and Human Services, 2013). However, the other three critical components of services, timeliness, and workforce must also be addressed if those newly insured Americans are going to be able to use their coverage. In general, there will be a need for an increased number of primary healthcare providers (PCPs) throughout the country, with an intensified need for PCPs in rural areas. Nearly 60 million rural Americans will have access to healthcare services through the ACA (U.S. Department of Health and Human Services, 2012), but there are fewer primary care providers in rural areas. Twenty percent of the nation’s population lives in rural areas; however, only 11% of the nation’s physicians practice in a rural setting. These statistics are projected to worsen as 27.5% of rural and 28.9% of remote rural physicians near retirement, 562
with a projected shortage of 85,000 full-time physicians in rural areas by 2020 and a shortage of 124,000 by 2025 (National Rural Health Association, 2012). The number of primary care physicians is not expected to increase. Decreases in the number of medical students interested in working in primary care (Brotherton, Rockey, & Etzel, 2005) have continued to affect access to health care. In 2008, only 264 medical students pursued a residency in primary care internal medicine compared to 575 in 1999 (Dotinga, 2011). Meanwhile, the number of nurse practitioners (NPs) responsible for primary care is growing. In the United States, about 134,000 NPs practice in primary care (Vestal, 2013), with 15.2% (16,666) working in rural areas (Skillman, Kaplan, Fordyce, McMenamin, & Doescher, 2012). NPs provide a substantial portion of primary care in rural areas compared to physicians. In 2012, there were 2.8 NPs for each 10,000 rural patients (Skillman et al., 2012), providing health care, health promotion, and disease prevention to the underserved, regardless of their insurance status, availability of transportation, or language. The purpose of this article is to describe difficulties related to the business-related aspects of practice in Journal of the American Association of Nurse Practitioners 26 (2014) 562–566 C 2014 American Association of Nurse Practitioners
NP social entrepreneurship
D. B. Sharp & D. Monsivais
transition to the role of a rural NP, and to give practice implications. The study is taken from a larger parent study of 24 rural NPs living throughout the United States.
Conceptual framework This study is based on a conceptual framework developed by Sharp (2010) that addressed the transition to rural practice for NPs (Figure 1). Many NPs transitioned into the role of a rural NP clinic owner, which can be described as a social entrepreneur. Social entrepreneurs have the qualities and behaviors associated with business entrepreneurs but they operate in the community out of concern and caring, not making money (Thompson, 2002). During the transition, the NP experiences acrossculture conflict recognition. They experience a feeling of marginal living; a push–pull tension felt being caught between two different roles. This is a feeling of not truly being an NP or a clinic owner and manager. The transition from the old to new role does not occur overnight, it is a transition affected by varying factors. In order to transition to a clinic owner/manager, the NP needs to have the knowledge and skills to be successful; without this knowledge the NP can have feelings of uncertainty and apprehension about the future. Across-culture conflict recognition occurs when the NP begins to understand the differences between the two roles and the contradicting cultural values, customs, behaviors, and norms. In response to these conflicts, the individual intentionally will adjust his/her responses to ease the cultural tension. NPs who are not confident or secure in their new role as a clinic owner/manager report anxiety, uncertainty, and stress in the transition and may return to their previous role if there are too many obstacles and conflicts. Others will strive to acquire new information that will assist with the transition to successful clinic owner and manager. The transition from the old role to the new is affected by personal, social, and professional adaptation, leading to success in both roles. Success in both roles leads to gratification with being both clinic manager and care provider.
Methods The study sample included 24 rural NPs living throughout the United States. The majority of the NPs were 51–60 years of age (45%) and females (93%). They were from diverse racial/ethnic backgrounds: 83% White non-Hispanic, 14% Hispanic, and 3% Black/African American. NPs were recruited from the National Health Service Corps database for interviews lasting from 15
min to 1 h. Data were collected using a focused ethnographic approach, using interviews held via Elluminate online media that offers both video and audio capabilities. Interviews were transcribed verbatim and analyzed by constant-comparison analysis, which led to identifying categories and themes. Following content analysis, the narrative text was analyzed for patterns, using a line-byline analysis throughout the data collection period. Relevant sentences and phrases were coded. Institutional Review Board approval was obtained from the University of Texas at El Paso.
Results Results demonstrated difficulties with role transition to social entrepreneur and the business aspects of practice. The NPs were very successful in their role as an NP; however they lacked the necessary skills and knowledge needed to manage clinic ownership.
Difficulties related to scope of practice, business skills, and role conflict Scope of practice. “When patients come in from other states that do not recognize nurse practitioners then the clinic only receives the co-pay.” This is because of the differences in nurse practice acts from state to state. Scope of practice for NPs is regulated by the board of nursing and by each state’s Nurse Practice Act (Christian, Dower, & O’Neil, 2007). Some states permit NPs to practice independently, others require the supervision or collaboration of a physician. NPs are willing and able to care for these individuals, however they have been under utilized because of state nurse practice acts. Changes have been made to some nurse practice acts because of the ACA. Recently, more states allowed independent full-autonomy NP practice; currently, 17 states and the District of Columbia have independent full-autonomy NP practice (Vestal, 2013). Business skills. The NPs perceived themselves as having a lack of business skills. This included reimbursement management; managerial skills; and maintaining billing, accounting, and financial records. “You never realize how much business you were not taught. Even to the point of coding it was mostly trial and error. We had to start from scratch . . . providing patient status to insurance companies, Medicare numbers.”
Nurse-managed clinics continue to depend on privatepay patients, third-party reimbursement, Medicaid and Medicare reimbursement, private grants, and government funding (Hansen-Turton, Ritter, & Torgan, 2008; Wilson, Whitaker, & Whitford, 2012). The patient populations in rural clinics include the 563
NP social entrepreneurship
D. B. Sharp & D. Monsivais
TransiƟon
Nursing Culture Intra-dependent Interdependent Dependent Expert
EducaƟon Marginal Living Across-Culture Conflict RecogniƟon Easing Cultural Tension Contextual/Personal Influences Lack of Anonymity Insider/Outsider IsolaƟon/Distance Self-Reliance
Expert
Rural NP role Autonomous Novice
Novice
Transition
Personal
Social
Professional
A d a p t a t i o n
Role Success
Gratification
Figure 1 Conceptual framework (Sharp, 2010).
uninsured, the underinsured, or patients living in poverty (Hansen-Turton et al., 2008). Patients who are unable to pay are often offered a sliding payment scale, based on their income, or a payment plan limiting income to the practice and threatening financial sustainability.
Other sources of income are from Medicaid and Medicare. NP reimbursement policies and procedures for collecting payments through Medicaid and Medicare (Elango, Hunter, & Winchell, 2007) are different from physicians’, leading to decreased income.
“I try to make my office visits as reasonable as possible . . . I even make payment arrangement with patients so that they can pay for their well-woman exam over a period of months . . . because I strongly believe in . . . getting people and getting them seen.”
“As a nurse practitioner your reimbursement rates are pretty much what they decide, our big thing . . . as far as reimbursement is trying to figure out how much the public will understand payment at time of service.”
564
D. B. Sharp & D. Monsivais
Currently, NP reimbursement through Medicare is at the rate of 80% of the actual charge or 85% of the fee schedule amount for physicians (American Association of Nurse Practitioners, 2013). Some patients have health insurance. Third-party reimbursement is contingent on being recognized as a medical home, primary care provider, or provider within the patient’s network. In a national survey, nearly half of the major insurance companies refused to credential NPs as primary care providers. In July 2009, only 52% of insurance companies accepted NPs as primary care providers (Hansen-Turton et al., 2008). Insurers not willing to credential NPs and establish reimbursement policies affect clinic incomes threatening the long-term sustainability of rural clinics. “I am barely making my overhead, and I’m still not paying myself a salary after a year and a half, and so I still need to have outside employment, I’m still working two days a week. It is slow going, . . . I don’t know what the long term sustainability of my practice is going to be.”
Role conflict. As an NP and a social entrepreneur, NPs opened clinics to offer health care to individuals. Once they established their clinical practices, they experienced conflict between taking care of patients and managing the clinical practice. The business aspect impacted their clinical practice, taking the NPs away from patients. “We are doing billing, we are doing the database . . . , we remodeled the outside of the clinic, . . . when you own your own place you give up a lot of care time.”
They demonstrated across-culture conflict. “I wish it did not take as much time, but I have to say owning your own clinic we have spent so much time doing that we probably only have, um probably sixty-five percent of actual patient care.” Another participant stated, “The farther I get from patient care the less I like it.” Without NPs, many people in rural areas would have no access to care at all. The NPs felt they had a social responsibility to provide health care to the rural community: “If I’m not here, nobody is here, there wasn’t a clinic here before.” Some established their own clinics to benefit the residents of the community; feeling that it was “almost a religious mission that somebody has to be there to take care of the community.”
Implications for practice The advent of the ACA means an increased need for healthcare access in rural areas. Increasing health access to rural residents will require an increase in the number of clinics, including clinics owed by NPs. Lack of knowledge related to how to start a business and how to de-
NP social entrepreneurship
velop a business plan are barriers (Elango et al., 2007) to NP-owned clinics. If NPs seek to be social entrepreneurs, it is essential they receive the necessary education and knowledge related to clinic management. Shirey (2007a) identified both enablers and disablers related to the business factors of social entrepreneurs. Enablers assist nurse entrepreneurs to be successful. Outside help from experts such as lawyers, accountants, business start-up counselors, and mentors can be useful. Disablers include perceived lack of business skills, particularly in the area of finance, legal issues, and running the day-today operations. U.S. nurses experience disablers when they are not educated in their traditional nursing programs with the necessary information to be successful nurse entrepreneurs. For nurse entrepreneurship to be developed, nursing education must ensure students are provided with the necessary information and skills. In northern Ireland, entrepreneurship education was established in 2000 through the Northern Ireland Centre for Entrepreneurship (NICENT). Education is provided in their undergraduate program based on an integration model. The first year focuses on students’ understanding and developing the skills of entrepreneurship, needs assessments, planning and delivering care including needed resources (Boore & Portner, 2011). The second year builds on the first year. The role and characteristics of entrepreneurs is examined including how entrepreneurs function alone and in teams. During the third year, students focus on management of change which concentrates on entrepreneurship knowledge with students developing skills through teamwork. Students examined models and strategies for change, the scope of entrepreneurship, how to identify entrepreneurial opportunities, market research, planning change, and financial management. To facilitate NP social entrepreneurs, NP programs throughout the United States need to strongly consider adding education related to finance, legal/regulation practices, strategic planning, leadership, and clinic management to the curriculum. With information incorporated in Masters of Nursing and Doctorate of Nursing Practice Programs, NPs will have the knowledge needed to be successful. NPs interested in owning a clinical practice, who have already completed their formal education, can gain knowledge related to clinic management by working or volunteering in an office setting, a community clinic or physician practice (Shirey, 2007b). Necessary skills can also be obtained through the MSN in Innovation and Intra/Entrepreneurship Program at Drexel University (http://drexel.edu/grad/programs/cnhp/innovation-andintra-entrepreneurship-in-advanced-nursing-practice/). 565
NP social entrepreneurship
Drexel University developed an online post-master’s nondegree program for nurses interested in learning about entrepreneurship (Shirey, 2007b). Additionally the University of Rochester in Rochester, New York, has a Center for Nursing Entrepreneurship to teach business strategy to nurses (http://www.son.rochester.edu/ welcome/#enterpreneurs). If NP entrepreneurs do not develop strategies or engage in strategic planning and marketing, they may not be successful (Guo, 2009). Financial management skills such as planning, reimbursement, and outcome measures are useful in attaining short- and long-term goals (Guo, 2009) and successful healthcare access to rural Americans.
References American Association of Nurse Practitioners. (2013). Fact sheet: Medicare reimbursement. Retrieved from http://www.aanp.org/practice/ reimbursement/68-articles/325-medicare-reimbursement Boore, J., & Portner, S. (2011). Education for entrepreneurship in nursing. Nurse Education Today, 31(2), 184–191. Brotherton, S. E., Rockey, P. H., & Etzel, S. I. (2005). US graduate medical education, 2004–2005: Trends in primary care specialties. JAMA, 294(9), 1075–1082. Christian, S., Dower, C., & O’Neil, E. (2007). Overview of NP scopes of practice in the United States. San Francisco: University of California. Retrieved from http://futurehealth.ucsf.edu/Content/29/2007--12 Overview of Nurse Practitioner Scopes of Practice In the United States Discussion.pdf Dotinga, R. (2011). Fewer med students training as primary-care doctors: Study. Health Day: US News and World Report. Retrieved from http://health.usnews.com/health-news/managing-your-healthcare/ healthcare/articles/2011/04/26/fewer-med-students-training-as-primarycare-doctors-study
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Elango, B., Hunter, G. L., & Winchell, M. (2007). Barriers to nurse entrepreneurship: A study of the process model of entrepreneurship. Journal of the American Academy of Nurse Practitioners, 19, 198–204. DOI: 10.1111/j.1745-7599.2007.00215.x Guo, K. L. (2009). Core competencies of the entrepreneurial leader in health care organizations. Health Care Manager, 28(1), 19–29. Hansen-Turton, T., Ritter, A., & Torgan, R. (2008) Insurers’ contracting policies on nurse practitioners as primary care providers: Two years later. Policy, Politics, and Nursing Practice, 9(4), 241–248. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18562764 National Rural Health Association. (2012). Health care workforce distribution andshortage issues for rural America. National Rural Health Association Policy Brief, 1–11. Retrived from www.ruralhealthweb.org Sharp, D. B. (2010). Factors related to the recruitment and retention of nurse practitioners in rural areas. Doctoral dissertation.University of Texas at El Paso, El Paso, TX. Retrieved from ProQuest at http://udini.proquest.com/view/factors-related-to-the-recruitment-goid: 613695577/ Shirey, M. R. (2007a). An evidence-based understanding on entrepreneurship in nursing. Clinical Nurse Specialist, 21(5), 234–240. Shirey, M. R. (2007b). Innovation and entrepreneurship. Clinical Nurse Specialist, 21(1), 16–21. Skillman, S. M., Kaplan, L., Fordyce, M. A., McMenamin, P. D., & Doescher, M. P. (2012). Understanding advanced practice registered nurse distribution in urban and rural areas of the United States using National Provider Identifier Data, 137. Retrieved from www.nursingworld.org/APRNdistrubitionreport Thompson, J. L. (2002). The world of the social entrepreneur. International Journal of Public Sector Management, 15(5), 412–431. http://dx.doi.org/ 10.1108/09513550210435746 U.S. Department of Health and Human Services. (2012). The Affordable Care Act – What does it mean for rural American. Retrieved from http://www.hhs.gov U.S. Department of Health and Human Services. (2013). Healthy people 2020. Retrieved from www.HealthyPeople.gov. Vestal, C. (2013). Nurse practitioners slowly gain autonomy. Stateline. Retrieved from www.kaiserhealthnews.org Wilson, A., Whitaker, N., & Whitford, D. (May 31, 2012). Rising to the challenge of health care reform with entrepreneurial and intrapreneurial nursing initiatives. OJIN: The Online Journal of Issues in Nursing, 17(2), Manuscript 5. 10.3912/OJIN.Vol17No02Man05
Decreasing barriers for nurse practitioner social entrepreneurship Dayle B. Sharp, PhD, MSN, McPH, FNP-BC (Clinical Assistant Professor) & Diane Monsivais, PhD, CNE, CRRN (Assistant Professor) School of Nursing, University of Texas at El Paso, El Paso, Texas
Keywords Nurse practitioners; entrepreneurship; rural; underserved. Correspondence Dayle B. Sharp, PhD, MSN, McPH, FNP-BC, School of Nursing, University of Texas at El Paso, El Paso, TX 79968. Tel: 915-747-5315; Fax: 915-747-7207; E-mail: [email protected] Received: 3 December 2013; accepted: 4 March 2014 doi: 10.1002/2327-6924.12126 Disclosure The authors report no competing interests.
Abstract Purpose: To describe difficulties associated with the business-related aspects of practice in role transition of rural nurse practitioners (NPs), and to give practice implications. Data sources: This focused ethnographic study derived data from semistructured interviews. Participants provided information about rural NP practice ownership and barriers. The sample consisted of 24 rural NPs living throughout the United States. The majority were 51–60 years of age (45%) and females (93%) who had been in rural practice for 1 to over 20 years. Conclusions: NP social entrepreneurs experience difficulties related to scope of practice, business skills, and role conflict. Implications for practice: To decrease barriers for NP clinic ownership and management, NPs need to receive education related to financing a rural practice, legal/regulatory practices, strategic planning, leadership, and clinic management.
Introduction/background “You never realize how much business you were not taught . . . ” (Study Participant)
As a result of the Affordable Care Act (ACA), millions of Americans will have health insurance for the first time. This important step toward reducing health disparities addresses coverage, one of the critical components of Healthy People 2020 (U.S. Department of Health and Human Services, 2013). However, the other three critical components of services, timeliness, and workforce must also be addressed if those newly insured Americans are going to be able to use their coverage. In general, there will be a need for an increased number of primary healthcare providers (PCPs) throughout the country, with an intensified need for PCPs in rural areas. Nearly 60 million rural Americans will have access to healthcare services through the ACA (U.S. Department of Health and Human Services, 2012), but there are fewer primary care providers in rural areas. Twenty percent of the nation’s population lives in rural areas; however, only 11% of the nation’s physicians practice in a rural setting. These statistics are projected to worsen as 27.5% of rural and 28.9% of remote rural physicians near retirement, 562
with a projected shortage of 85,000 full-time physicians in rural areas by 2020 and a shortage of 124,000 by 2025 (National Rural Health Association, 2012). The number of primary care physicians is not expected to increase. Decreases in the number of medical students interested in working in primary care (Brotherton, Rockey, & Etzel, 2005) have continued to affect access to health care. In 2008, only 264 medical students pursued a residency in primary care internal medicine compared to 575 in 1999 (Dotinga, 2011). Meanwhile, the number of nurse practitioners (NPs) responsible for primary care is growing. In the United States, about 134,000 NPs practice in primary care (Vestal, 2013), with 15.2% (16,666) working in rural areas (Skillman, Kaplan, Fordyce, McMenamin, & Doescher, 2012). NPs provide a substantial portion of primary care in rural areas compared to physicians. In 2012, there were 2.8 NPs for each 10,000 rural patients (Skillman et al., 2012), providing health care, health promotion, and disease prevention to the underserved, regardless of their insurance status, availability of transportation, or language. The purpose of this article is to describe difficulties related to the business-related aspects of practice in Journal of the American Association of Nurse Practitioners 26 (2014) 562–566 C 2014 American Association of Nurse Practitioners
NP social entrepreneurship
D. B. Sharp & D. Monsivais
transition to the role of a rural NP, and to give practice implications. The study is taken from a larger parent study of 24 rural NPs living throughout the United States.
Conceptual framework This study is based on a conceptual framework developed by Sharp (2010) that addressed the transition to rural practice for NPs (Figure 1). Many NPs transitioned into the role of a rural NP clinic owner, which can be described as a social entrepreneur. Social entrepreneurs have the qualities and behaviors associated with business entrepreneurs but they operate in the community out of concern and caring, not making money (Thompson, 2002). During the transition, the NP experiences acrossculture conflict recognition. They experience a feeling of marginal living; a push–pull tension felt being caught between two different roles. This is a feeling of not truly being an NP or a clinic owner and manager. The transition from the old to new role does not occur overnight, it is a transition affected by varying factors. In order to transition to a clinic owner/manager, the NP needs to have the knowledge and skills to be successful; without this knowledge the NP can have feelings of uncertainty and apprehension about the future. Across-culture conflict recognition occurs when the NP begins to understand the differences between the two roles and the contradicting cultural values, customs, behaviors, and norms. In response to these conflicts, the individual intentionally will adjust his/her responses to ease the cultural tension. NPs who are not confident or secure in their new role as a clinic owner/manager report anxiety, uncertainty, and stress in the transition and may return to their previous role if there are too many obstacles and conflicts. Others will strive to acquire new information that will assist with the transition to successful clinic owner and manager. The transition from the old role to the new is affected by personal, social, and professional adaptation, leading to success in both roles. Success in both roles leads to gratification with being both clinic manager and care provider.
Methods The study sample included 24 rural NPs living throughout the United States. The majority of the NPs were 51–60 years of age (45%) and females (93%). They were from diverse racial/ethnic backgrounds: 83% White non-Hispanic, 14% Hispanic, and 3% Black/African American. NPs were recruited from the National Health Service Corps database for interviews lasting from 15
min to 1 h. Data were collected using a focused ethnographic approach, using interviews held via Elluminate online media that offers both video and audio capabilities. Interviews were transcribed verbatim and analyzed by constant-comparison analysis, which led to identifying categories and themes. Following content analysis, the narrative text was analyzed for patterns, using a line-byline analysis throughout the data collection period. Relevant sentences and phrases were coded. Institutional Review Board approval was obtained from the University of Texas at El Paso.
Results Results demonstrated difficulties with role transition to social entrepreneur and the business aspects of practice. The NPs were very successful in their role as an NP; however they lacked the necessary skills and knowledge needed to manage clinic ownership.
Difficulties related to scope of practice, business skills, and role conflict Scope of practice. “When patients come in from other states that do not recognize nurse practitioners then the clinic only receives the co-pay.” This is because of the differences in nurse practice acts from state to state. Scope of practice for NPs is regulated by the board of nursing and by each state’s Nurse Practice Act (Christian, Dower, & O’Neil, 2007). Some states permit NPs to practice independently, others require the supervision or collaboration of a physician. NPs are willing and able to care for these individuals, however they have been under utilized because of state nurse practice acts. Changes have been made to some nurse practice acts because of the ACA. Recently, more states allowed independent full-autonomy NP practice; currently, 17 states and the District of Columbia have independent full-autonomy NP practice (Vestal, 2013). Business skills. The NPs perceived themselves as having a lack of business skills. This included reimbursement management; managerial skills; and maintaining billing, accounting, and financial records. “You never realize how much business you were not taught. Even to the point of coding it was mostly trial and error. We had to start from scratch . . . providing patient status to insurance companies, Medicare numbers.”
Nurse-managed clinics continue to depend on privatepay patients, third-party reimbursement, Medicaid and Medicare reimbursement, private grants, and government funding (Hansen-Turton, Ritter, & Torgan, 2008; Wilson, Whitaker, & Whitford, 2012). The patient populations in rural clinics include the 563
NP social entrepreneurship
D. B. Sharp & D. Monsivais
TransiƟon
Nursing Culture Intra-dependent Interdependent Dependent Expert
EducaƟon Marginal Living Across-Culture Conflict RecogniƟon Easing Cultural Tension Contextual/Personal Influences Lack of Anonymity Insider/Outsider IsolaƟon/Distance Self-Reliance
Expert
Rural NP role Autonomous Novice
Novice
Transition
Personal
Social
Professional
A d a p t a t i o n
Role Success
Gratification
Figure 1 Conceptual framework (Sharp, 2010).
uninsured, the underinsured, or patients living in poverty (Hansen-Turton et al., 2008). Patients who are unable to pay are often offered a sliding payment scale, based on their income, or a payment plan limiting income to the practice and threatening financial sustainability.
Other sources of income are from Medicaid and Medicare. NP reimbursement policies and procedures for collecting payments through Medicaid and Medicare (Elango, Hunter, & Winchell, 2007) are different from physicians’, leading to decreased income.
“I try to make my office visits as reasonable as possible . . . I even make payment arrangement with patients so that they can pay for their well-woman exam over a period of months . . . because I strongly believe in . . . getting people and getting them seen.”
“As a nurse practitioner your reimbursement rates are pretty much what they decide, our big thing . . . as far as reimbursement is trying to figure out how much the public will understand payment at time of service.”
564
D. B. Sharp & D. Monsivais
Currently, NP reimbursement through Medicare is at the rate of 80% of the actual charge or 85% of the fee schedule amount for physicians (American Association of Nurse Practitioners, 2013). Some patients have health insurance. Third-party reimbursement is contingent on being recognized as a medical home, primary care provider, or provider within the patient’s network. In a national survey, nearly half of the major insurance companies refused to credential NPs as primary care providers. In July 2009, only 52% of insurance companies accepted NPs as primary care providers (Hansen-Turton et al., 2008). Insurers not willing to credential NPs and establish reimbursement policies affect clinic incomes threatening the long-term sustainability of rural clinics. “I am barely making my overhead, and I’m still not paying myself a salary after a year and a half, and so I still need to have outside employment, I’m still working two days a week. It is slow going, . . . I don’t know what the long term sustainability of my practice is going to be.”
Role conflict. As an NP and a social entrepreneur, NPs opened clinics to offer health care to individuals. Once they established their clinical practices, they experienced conflict between taking care of patients and managing the clinical practice. The business aspect impacted their clinical practice, taking the NPs away from patients. “We are doing billing, we are doing the database . . . , we remodeled the outside of the clinic, . . . when you own your own place you give up a lot of care time.”
They demonstrated across-culture conflict. “I wish it did not take as much time, but I have to say owning your own clinic we have spent so much time doing that we probably only have, um probably sixty-five percent of actual patient care.” Another participant stated, “The farther I get from patient care the less I like it.” Without NPs, many people in rural areas would have no access to care at all. The NPs felt they had a social responsibility to provide health care to the rural community: “If I’m not here, nobody is here, there wasn’t a clinic here before.” Some established their own clinics to benefit the residents of the community; feeling that it was “almost a religious mission that somebody has to be there to take care of the community.”
Implications for practice The advent of the ACA means an increased need for healthcare access in rural areas. Increasing health access to rural residents will require an increase in the number of clinics, including clinics owed by NPs. Lack of knowledge related to how to start a business and how to de-
NP social entrepreneurship
velop a business plan are barriers (Elango et al., 2007) to NP-owned clinics. If NPs seek to be social entrepreneurs, it is essential they receive the necessary education and knowledge related to clinic management. Shirey (2007a) identified both enablers and disablers related to the business factors of social entrepreneurs. Enablers assist nurse entrepreneurs to be successful. Outside help from experts such as lawyers, accountants, business start-up counselors, and mentors can be useful. Disablers include perceived lack of business skills, particularly in the area of finance, legal issues, and running the day-today operations. U.S. nurses experience disablers when they are not educated in their traditional nursing programs with the necessary information to be successful nurse entrepreneurs. For nurse entrepreneurship to be developed, nursing education must ensure students are provided with the necessary information and skills. In northern Ireland, entrepreneurship education was established in 2000 through the Northern Ireland Centre for Entrepreneurship (NICENT). Education is provided in their undergraduate program based on an integration model. The first year focuses on students’ understanding and developing the skills of entrepreneurship, needs assessments, planning and delivering care including needed resources (Boore & Portner, 2011). The second year builds on the first year. The role and characteristics of entrepreneurs is examined including how entrepreneurs function alone and in teams. During the third year, students focus on management of change which concentrates on entrepreneurship knowledge with students developing skills through teamwork. Students examined models and strategies for change, the scope of entrepreneurship, how to identify entrepreneurial opportunities, market research, planning change, and financial management. To facilitate NP social entrepreneurs, NP programs throughout the United States need to strongly consider adding education related to finance, legal/regulation practices, strategic planning, leadership, and clinic management to the curriculum. With information incorporated in Masters of Nursing and Doctorate of Nursing Practice Programs, NPs will have the knowledge needed to be successful. NPs interested in owning a clinical practice, who have already completed their formal education, can gain knowledge related to clinic management by working or volunteering in an office setting, a community clinic or physician practice (Shirey, 2007b). Necessary skills can also be obtained through the MSN in Innovation and Intra/Entrepreneurship Program at Drexel University (http://drexel.edu/grad/programs/cnhp/innovation-andintra-entrepreneurship-in-advanced-nursing-practice/). 565
NP social entrepreneurship
Drexel University developed an online post-master’s nondegree program for nurses interested in learning about entrepreneurship (Shirey, 2007b). Additionally the University of Rochester in Rochester, New York, has a Center for Nursing Entrepreneurship to teach business strategy to nurses (http://www.son.rochester.edu/ welcome/#enterpreneurs). If NP entrepreneurs do not develop strategies or engage in strategic planning and marketing, they may not be successful (Guo, 2009). Financial management skills such as planning, reimbursement, and outcome measures are useful in attaining short- and long-term goals (Guo, 2009) and successful healthcare access to rural Americans.
References American Association of Nurse Practitioners. (2013). Fact sheet: Medicare reimbursement. Retrieved from http://www.aanp.org/practice/ reimbursement/68-articles/325-medicare-reimbursement Boore, J., & Portner, S. (2011). Education for entrepreneurship in nursing. Nurse Education Today, 31(2), 184–191. Brotherton, S. E., Rockey, P. H., & Etzel, S. I. (2005). US graduate medical education, 2004–2005: Trends in primary care specialties. JAMA, 294(9), 1075–1082. Christian, S., Dower, C., & O’Neil, E. (2007). Overview of NP scopes of practice in the United States. San Francisco: University of California. Retrieved from http://futurehealth.ucsf.edu/Content/29/2007--12 Overview of Nurse Practitioner Scopes of Practice In the United States Discussion.pdf Dotinga, R. (2011). Fewer med students training as primary-care doctors: Study. Health Day: US News and World Report. Retrieved from http://health.usnews.com/health-news/managing-your-healthcare/ healthcare/articles/2011/04/26/fewer-med-students-training-as-primarycare-doctors-study
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Elango, B., Hunter, G. L., & Winchell, M. (2007). Barriers to nurse entrepreneurship: A study of the process model of entrepreneurship. Journal of the American Academy of Nurse Practitioners, 19, 198–204. DOI: 10.1111/j.1745-7599.2007.00215.x Guo, K. L. (2009). Core competencies of the entrepreneurial leader in health care organizations. Health Care Manager, 28(1), 19–29. Hansen-Turton, T., Ritter, A., & Torgan, R. (2008) Insurers’ contracting policies on nurse practitioners as primary care providers: Two years later. Policy, Politics, and Nursing Practice, 9(4), 241–248. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18562764 National Rural Health Association. (2012). Health care workforce distribution andshortage issues for rural America. National Rural Health Association Policy Brief, 1–11. Retrived from www.ruralhealthweb.org Sharp, D. B. (2010). Factors related to the recruitment and retention of nurse practitioners in rural areas. Doctoral dissertation.University of Texas at El Paso, El Paso, TX. Retrieved from ProQuest at http://udini.proquest.com/view/factors-related-to-the-recruitment-goid: 613695577/ Shirey, M. R. (2007a). An evidence-based understanding on entrepreneurship in nursing. Clinical Nurse Specialist, 21(5), 234–240. Shirey, M. R. (2007b). Innovation and entrepreneurship. Clinical Nurse Specialist, 21(1), 16–21. Skillman, S. M., Kaplan, L., Fordyce, M. A., McMenamin, P. D., & Doescher, M. P. (2012). Understanding advanced practice registered nurse distribution in urban and rural areas of the United States using National Provider Identifier Data, 137. Retrieved from www.nursingworld.org/APRNdistrubitionreport Thompson, J. L. (2002). The world of the social entrepreneur. International Journal of Public Sector Management, 15(5), 412–431. http://dx.doi.org/ 10.1108/09513550210435746 U.S. Department of Health and Human Services. (2012). The Affordable Care Act – What does it mean for rural American. Retrieved from http://www.hhs.gov U.S. Department of Health and Human Services. (2013). Healthy people 2020. Retrieved from www.HealthyPeople.gov. Vestal, C. (2013). Nurse practitioners slowly gain autonomy. Stateline. Retrieved from www.kaiserhealthnews.org Wilson, A., Whitaker, N., & Whitford, D. (May 31, 2012). Rising to the challenge of health care reform with entrepreneurial and intrapreneurial nursing initiatives. OJIN: The Online Journal of Issues in Nursing, 17(2), Manuscript 5. 10.3912/OJIN.Vol17No02Man05
