Transcript: How Primary Care Offices Work for New Nurse Practitioners

​Liz Rohr:
Well, hey there. It's Liz Rohr from Real World NP. You are watching NP Practice Made Simple. Weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. In this week's video I'm going to be talking about how primary care offices work in the way of them being a business. From the business side perspective. And why am I talking about this? The reason I want to make a video about this is that this is something that I learned on the job as a nurse practitioner several months to a year in. And understanding how the business of a primary care office works impacts so many facets of your job as a new nurse practitioner. And it helps you negotiate terms of your job. Whether or not you're looking for a new job, whether you're trying to improve the experience of your current job, or you're leaving your current job for a new one because it's not working out.
 

And the reason I'm talking about this is that next week I'm going to expand on this further, but this is the foundational information that you need to know about how primary care offices actually work. And the other reason I'm talking about this and talking about this topic this week and in the coming weeks... at least one other video, if not more, depending on the demand, the desire, is that when I work with mentees one-on-one... I mentor nurse practitioners one-on-one as a part of Real World NP across the country. And I've been doing so for about a year and a half, almost two years now. And the themes are so resoundingly similar. And so if we're talking about this right now in my one-on-one calls, it's likely going to be helpful for you as well. And also I think a lot of us are feeling really exhausted and burnt out by the last year with COVID and a lot of the conversations of the struggles that people are having.
 

There are certain things that we need to do in terms of our own skill set of time management skills and learning how to write our notes and how to conduct patient visits. But there are other factors that are outside of our control and outside of what we are responsible for in terms of like, "This is a me problem." It's important to recognize when it's a systemic problem of the clinic and where that line is, and what we can do about it. So anyway, to be continued on that; the pitfalls and dysfunctional clinic settings. A little nervous to talk about it that way. Anyway, we'll see. We'll see how it goes. Tune in next week. But anyway, back to the topic of this video: how primary care offices work. Clinics are a business. We are there to take excellent care of our patients, to make an impact in the world, impact in our communities, and so is the clinic as a business.
 

However, when it comes to Maslow's hierarchy of needs in that pyramid we learned in nursing school, the foundation of some... we can't be self-actualized until we have food, water, and shelter. So in terms of that Maslow's hierarchy of needs, when it comes to a business, they can't function without revenue. They can't function without money. And so they need to do that bare minimum. Okay, so what does that have to do with you? The way that primary care clinics work, it depends on what type of setting we're talking about. Whether it's a hospital-based system, whether it's a private practice, whether it's a community health center that's a Federally Qualified Health Center. The structures vary a little bit from site to site but typically they are the same. So at bare minimum you have a provider. A nurse practitioner, a physician, a PA, a DO. Somebody who is a provider-level provider. They see patients. You see patients. You and I see patients in the clinic.
 

When we see a patient, we submit an insurance claim. We do a billing code for that visit. And if you haven't checked out the billing and coding video that I've done, I'll link to that in the comments below. And also just know I'm working on an updated video for the updated guidelines. However, when you see a patient you submit a bill to the insurance company, a claim, and then the amount of money that you get back depends on the level and acuity of the patient visit. Again, I talk about that in the billing and coding video but, typically speaking, it's a level two to five. Two to four for the most part. And level four is more complicated, more time consuming, more high acuity patients. And level two is more of a single issue that is very straightforward. And depending on that level, you get more money.
 

And so that's why RVUs exist. And I'm not going to go into RVUs on this visit... on this visit. This video. But RVUs have to do with how many patients you're seeing in a day compared to their level of acuity. For example, if you see 10 patient visits and it's a level four compared to 10 patient visits that are level two, that's very different. It's a lot higher workload to see 10 level four visits. And that has to do with the RVU calculation. I can get into that more if you're interested. But anyway, it talks about your productivity, quote unquote, air quotes. I don't love that term, but that's how that works. In the Federally Qualified Health Center setting, you still submit claims to insurance companies but if you are submitting a private insurance compared to a Medicaid insurance or state-based funding, that's different because the reimbursement... and I'm not a billing specialist. All I can speak to is what I understand. And where I practice in Massachusetts, the case for our clinic, which is a Federally Qualified Health Center, is that we submit a bill to the insurance.
 

And there are differences between levels two and four but not really. Not enough to write home about. And so for us in the Federally Qualified Health Center setting, it's about numbers. It's about, how many patients did you see in one day? And less so about that RVU statistic of, how, "productive are you?" Did you see 20 patients that were level four versus 20 patients who were level two, et cetera? We still look at that in the setting that I practice but, again, less important. And that's a whole other conversation in general. So going back to how primary care clinics work. We are providers in a clinic. Bare minimum, to have a clinic you need one person who can bill for visits or accept cash payment if it's a boutique practice or it's a cash-paying sliding scale practice. Things like that.
 

And then who are the other people that work there? It totally varies depending on the setting, but likely you have some supervisor if you're a new nurse practitioner who is a physician or an NP depending on the state that you practice, who is either your supervisor, a colleague, or a medical director. Typically, most sites have some sort of assistant staff to the providers where there's a medical assistant who does things like bring patients into the rooms, check vital signs, potentially reconcile medications, do phone calls back to patients, things like that. And you may also have nurses. And the nurses' role may depend on the rest of the staff. They might do education, they might do nurse visits where they give injections of vaccines or do blood pressure checks or do diabetes education visits. Or they might do things like case management. And it really depends on the clinic.
 

The other components of your clinic might be an office manager who oversees all of the staff that work there and the administrative staff who answers the phone calls in a call center or works at the front desk and verifies insurance, checks patients in, calls patients back. It really depends on the roles defined in your clinic. And then some clinics have many more people involved. And so there might be a chief operating officer, there might be a medical director or chief medical officer. There might be a CFO, CEO. And typically if there is those C-suite people, there is a board of directors. And the board of directors oversees the CEO. That's kind of like their boss. So I want to take a step back for a second. When it comes to income, where does money come from in the clinic, aside from what I've already said.
 

Providers see patients, they bill insurance, and then the insurance gives you money back. That money pays all the bills. However, there's also additional funding that you may see from a clinic. Specifically, again, I can mainly speak to Federally Qualified Health Centers because that's my setting of practice. Practice setting. Setting of practice. I don't know. But what I understand from the FQHCs that I'm familiar with in the state that I practice is that about 70% of our funding comes from providers seeing patients. The other 30% comes from grant funding. Grants are things that you apply for, to government grants or organizational grants where you apply. There's some sort of application process to some specific topic. And you can say, "Hey, I really want to start an HIV care initiative at my clinic." "How are we going to pay for that?" Is the question you'll likely get from your supervisor or whoever runs your clinic because it has to come from somewhere.
 

So you can apply for grants, you yourself or there might be a grant-writer for your clinic. It really just depends. The other part of it for Federally Qualified Health Centers when it relates to funding is that there's something called a 403(b) pharmacy. And those pharmacies are specific pharmacies attached to Federally Qualified Health Centers that receive special government funding to be able to offer discounted medications to patients. And I don't understand the full details of that but, typically speaking, we're encouraged to have patients get their medications there because, number one, it saves them money, but also we get a higher reimbursement back. And again, that's all I can speak to on that end.
 

But that is another component of the revenue. So in this video I really just am setting the groundwork for further videos that I'm going to be making about time management because, like I said at the beginning of this video, so many new nurse practitioners are focused on where their deficits are in terms of skill or knowledge or what they can be doing better, what they're not doing good enough which, again, has its merits. We're all learning how to do our jobs better. But it's also really important to acknowledge and make sense of what's not working in their clinic setting.
 

So as a new nurse practitioner, just as an example of how this is related, and I'll talk more about this next week, but when it comes to scheduling, typically, ideal world of what I understand and what I've seen from the people that I work with and in my own clinic setting in my real life, is that there's a template of your schedule. For your schedule, there is likely some sort of calendar rule. There's different kinds of visits. There's new patients, physicals, well child checks, procedures. There's also returning patients with chronic conditions. There's also urgent care sick visits that are made the same day or the next day. And again, I don't want to get too much into the weeds in this video but, as an example, there's typically some sort of template where there's a rule of, you're only going to see two new patients every four hours or block or session. However you call it.
 

Our clinic calls it sessions. But there are four hour sessions and there's only two to three new patients and/or physicals, they're lumped in the same category, because they take a lot of time. And then, number one, if you don't have that, that's that's disorienting and can be really stressful. And then the other thing is, if your staff are not abiding by the agreed upon rules around your schedule and what patients go where, when you have a break, when you have a lunch, et cetera, et cetera.
 

So anyway, in next week's video I'm going to be talking a little bit more about those components of... to understand what's happening with that ideal world is not matching the real world situation with scheduling mishaps and seeing too many physicals, et cetera, et cetera. I'll talk more about that next week as it relates to the foundations of understanding how the business works.
 

But yeah, hopefully this video was helpful as a foundational piece of information and it can also help you going forward in understanding your role in the clinic and what you bring to the table, and what you have to negotiate with, and what you have to ask with. But anyway, if you have not grabbed the Ultimate Resource Guide for the New NP, head over to realworldnp.com/guide. You'll get these videos sent straight to your inbox every week with notes from me, patient stories, and bonuses I really just don't share anywhere else. Thank you so very much for watching. Hang in there, and I'll see you soon.