The Business Side of Health Care - Michael Ipock, MSN, APRN, AGPCNP-BC, FNP-BC

Welcome to frontline nursing, a podcast that recognizes the impact nurses have on our lives and our communities. Throughout this series, we'll talk with those on the front lines of health care to hear about the issues impacting the nursing workforce, insights from their personal journeys, and what inspires them. I am your host, Rain of the Torno. Thanks for joining us and let's get started. My guest today is Michael Ipach. Michael is a board-certified family nurse practitioner and the founder of Wiregrass Direct Primary Care in Wesley, Chapel, Florida. Michael has more than a decade of experience across a cute and primary care and we're here to talk about his passionate advocacy for addressing nurse practitioner issues in the state of Florida. Welcome, Michael. Thank you for being here today. Thank you. Problem. Awesome. So tell our listeners a bit about your role because you are in advanced practice registered nurse, but your license sure doesn't end there in the state of Florida. You are actually licensed as an autonomous practice, advanced practice registered nurse, an autonomous advanced practice registered nurse. What does that mean for our listeners? Well, back in, I know this has been up for some debate for quite a while whether nurse practitioners can practice without a collaborating physician. So most of the time for as far as nurse practitioners have been in the profession, we had to work under a physician or in collaboration with the physician. And that required a physician to be either in the building or within a geographical location of where you were practicing so that they were able to be there for you to ask questions where for just any educational oversight. And nurse practitioners have been pushing for autonomy for quite a while. And in Florida and July of 2020, dissentists did sign a bill allowing us to practice autonomously without that physician oversight or collaboration. So what that means for nurse practitioners is we were able to open our own office and care for patients, only in the primary care setting was this a lot. The bill does not address nurse practitioners practicing outside of the primary care role. It's strictly for primary care. So I was able to leave the practice where I was working and open an office where I saw there was a need in the West of Chapel area and I began seeing patients by myself. Or just basically rented a small room and started seeing patients and tried my best to see what happened, go from there. So amazing. Let's start with really what does that look like. You are certified, you are board certified as a family nurse practitioner, you were working in an established office, but you saw the need and had the courage to be able to go solo and open your own practice in Westley Chapel. For those not familiar with the Westley Chapel area in Florida, it is a booming area. It is in the West Central region, Tampa Bay region. Westley Chapel is considered a suburb of Tampa, a bit northeast. Correct me if I'm wrong, I'm trying to think of a map in my mind. West, this is the area that I actually moved to when we relocated to Florida because all of that growth was so exciting to us, to my family at the time that we moved, but I never imagined that the growth over the last five to six years would be so tremendous as it has been. So tell me what is that like as a provider, because with that growth increases the demand for health care and for services, and so talk about your courage to open that practice while you did and the services that this growing population is requiring of you. Well, interesting enough, I opened just prior to COVID in 2019, I think it was August to 2019 is when I first hung single and opened my doors and it was very slow to start with. But a lot of people do not understand nurse tractors control. So they have similar questions that everyone's asking is, what does that mean and what allows us to practice basically just medicine and full with the one exception of signing for marijuana. So that's one thing that we cannot do, but other than that, we basically perform the same procedures diagnosis and treatment plans as MD or DIA would in the prime of their sentence. So this is a very daunting task to go solo and open their own office, especially pre-COVID error. This was a crying kind, but luckily I was one of the first offices I actually offered IV Monk Hall antibody infusions and treatment for COVID while a lot of offices were closing. And that actually helped me grow quite a bit during that time. And what that led to was needing to hire staff and additional employees to help me handle the influx of patients and grow up to the area because during that time, during COVID post-COVID, Wesley Chapel experienced quite a growth. It was one of the fastest growing counties in the United States. So it is a lot of 30 and 40-year-old families, the schools here are great. So there was a lot of reasons to come to this area post-COVID. Michael, what about all of the knowledge and the skills that you need as a nurse, as an advanced practice registered nurse, opening your own business? You know, those aren't always the skills that you taught in nursing school, how to run a business. And you just mentioned you had to hire staff, you were growing fast. What did you do to make sure that you were prepared for that role? That's a lot. I went to a lot of meetings, Pasco Economic Development here in Pasco County offers some assistance. And I just sought out other entrepreneurship and business owners in my area and help from anybody in the community that had any information regarding businesses and employment and employment practices, you know, how to -- there's just so much involved with the licensure. You know, when you're practicing solo, you can just focus on your own APR and licensure. But when you start having employees or another provider, you need to make the transition to, you know, health care, which is a different license through the Department of Business and Professional Responsibilities. So it's licensed different than your health care license. And that comes with its own, you know, rules and regulations and, you know, restrooms at the county for, you know, waste or biohazard products. There's just so much involved that really, we don't talk about, you know, in school for sure. Business -- I have a history of owning businesses, so, you know, I was -- I have many jobs, but one of the jobs was obviously in managing people. There was a general manager of like KFC, well, that's food restaurants. So I had experience with managing people. And then I also, back in '04, I owned a coffee rosary in Southwest Missouri that's still in business today. I ended up selling it when I got into health care. But so the entrepreneur part of was there. And then once I learned the medical side of things, it was just combining those things. But it really takes a team business person to go into health care because it is one of the largest businesses in the United States. You're exactly right. And thank you for bringing that to our attention and part of the conversation because health care is in industry and workforce development transcends industries. So you may have had that experience previously in a restaurant industry that you mentioned. But I'm sure that transcends as you're trying to recruit higher, develop professionally people who want to work for your company. So thanks for bringing that to the conversation. And I really appreciate how you blended your life skills previously with your health care expertise to be able to go forward. Michael, another thing that I heard you saying in that answer, and I wonder if you can elaborate a little bit on is what I heard was the importance of networking and mentorship in the new role. And that's a common theme that we hear through our podcast episodes on Frontline Nursing. And also throughout nursing, the importance of networking, professionally, finding others who are doing things similar to you so you can build on and also finding mentors. So you mentioned that you found some of that in like the chamber and the in the county organizations. But elaborate on the importance of that, please. Yeah, I mean, obviously, like you said, it is a business, unfortunately, it's the industry that we've inherited. And to navigate the business side of health care, it's very hard in just to help your aspects in medical care alone, not even thinking about the licensing and permitting and things that have to go through your county and state, you know, health and business licensures. And finding someone that has done things and as far as the business side of things, it really, you know, it doesn't have to be medical per se, but they are going to know a lot of resources about how they went about getting licenses and revoked and ensured for their particular profession, you know, because I think attorneys, you know, laborers, anybody that has any type of entrepreneur job, or they've rated in any industry, they had to go through some type of regulations, you know, the state or county, which you're trying to practice, perform services. So and then on the medical side, it's good to find people who have gone into their own health care business. And a lot of times, if you can't find anyone local, you know, I joined a lot of Facebook groups that allow me to implement and share ideas and knowledge that I needed. And that is simplest as, you know, hey, I need a consent form and form an IED, where do I find that? How do I go about that? What does it need to say? You know, and obviously you should consult attorneys with all your documentation, but, you know, you got to have, you got to start somewhere. I appreciate that, much appreciated that perspective. I want to shift gears, if you will, with our conversation and talk about supply and demand to them, you know, looking at health care as an industry has a business, we have to make sure that we have enough nurses to care for the people in the visitors of Florida. It's actually the Florida Center for Nursing's Vision that the health care needs of the residents and the visitors of Florida are met by a competent and sufficient nursing workforce. And that includes APRNs. And so what are you seeing in practice? Because I can read articles, I can evaluate the research from the Florida Center for Nursing that will evaluate adequacy of the supply of nurse practitioners. But what are you seeing in practice, specifically in Wesley Chapel, which is part of one of the fastest growing counties in the United States? Do we have enough practitioners to care for the people that need health care? That's a great question, right? So we do have enough licensed providers. The problem is they're just not practicing primary care for sure. This has been a problem for several years that I've picked up in practice. I'm a clinical preceptor for quite a few colleges. I have Himalayan agreements with, which is at the memorandum of understanding that something that the university's entering to a memorandum of understanding to allow students to practice in a location, so that I have those agreements in place with a lot of universities. And I precept students, and I precepted close to 400 students over the past six years. And less than 1% of those students have gone into primary care. And it becomes a challenge because primary care is so extensive, you have to know so much knowledge. And a lot of nurses had, you know, they just worked in one area of a hospital, so they may have a limited knowledge, and we expect the institutions, the universities to teach in a very short amount of time, an entire medical class that would prepare that nurse to perform primary care services, and a lot of times, sometimes it's pretty inadequate for that person to graduate and become a primary care provider on day one. They do need usually additional training, and we've been discussing that in practice, like residency programs that will help allow that transition from that R and R extra nurse to that side role, and do that nurse practitioner provider role. One of the largest barriers that I've saw in primary care is the financial barrier, the financial bill, because post-COVID, R extra nurses actually had quite an increase in their pay. And, you know, it's pretty common that a nurse makes six figures nowadays. And without a full understanding of the business of health care, whenever we graduate, as a nurse practitioner, we expect an increase in pay. I mean, we just went to, you know, a university, we paid out a lot of money, and we're graduating, and we need that additional funds to pay back to the loans, and we're performing at a higher level of care, and we have a higher responsibility. So we kind of come out expecting, you know, it's pretty common that we see, you know, nurse practitioners who apply for a job, they're asking for one, you know, 130,000, 150,000 a year, and it's really, as a business, it's not a good investment to pay someone that money if they can't perform the job. And it's not necessarily that they don't provide for a care, you know, that's the question is, as a business perspective, you know, how much money are they bringing in as a provider, and it's that, what you kill model, that is same as an attorney, or any other, you know, practice profession, it's, they get paid off of what they do, and if they aren't performing the procedures or the visits that they need to, then it just, the money just isn't there. So that is a big reason why a lot of the nurse practitioners who graduate will not enter the primary care, because it is one of the lower paying expertise, because you can choose to go into a specialty, and it's going to have a lot higher pay, that's adequate when the primary care just isn't there, so we want you to know the most knowledge, and what the least amount of money. So I find that it's really hard to convince the nurse practitioners, unless they, you know, I feel like I care so deeply for my patients, and I want them to get the best care possible, and I definitely am not here for the money, though, and that's, you know, partly why I wanted to, you know, come on and talk about it as, you know, it's, we really need help in that primary care role. We are several thousand, according to the statistics for Pasco County, we're several thousand providers short here in the county. I was just looking at leasing a new place the other day, and one of the, the, I guess on the demographic sheet for the local statistics, it said that, you know, it's expected that we be over 3000 primary care providers short in a short amount of time, and it's, it's scary to think about, like who's going to be taking care of all these patients, and primary care is preventative medicine, that's where we need the most help. So what are we going to do as a nation, you know, to help fix this problem? That's the key question right there, is how are we going to change the culture of the way healthcare is delivered in United States of America and switch it from a focus on tertiary care to primary care? That's a huge undertaking that I hope we are pointing towards. I want to take a deeper dive into some of what you had mentioned with salary and the importance of not just looking at the number of licensed nurses to determine if we have enough providers to deliver care, but really looking at it from the different perspective and the complexity which you just introduced us to. You know, I feel like so often I am asked in my role, do we have enough nurses? And I mean, I can't answer that yes or no. It's, it's a yes but or no but or no end in a yes and, but identifying just because a nurse is licensed doesn't necessarily mean they are employed or employed full time. And just because a nurse is licensed doesn't mean they're working in the specialty area or the healthcare setting where they're needed the most. And you elaborated on that in primary care. And you mentioned, first of all, thank you for precepting so many students because thank you. But when you're saying that you're precepting them in a primary care area and less than 1% approximately are going into primary care, where are the nurse practitioners going? What are they seeking? And how can we do a better job of recruiting to primary care knowing the market in equity with salary and all of the other demands? What's your suggestion? What is your recommendation? How are you going to solve this problem for us, Michael? Great question. Well, you know, the, the industry, healthcare in general, we work on to and in primary care specifically, we work in one of two ways. We are either fee for service, which means we get paid to do a service for a patient or we are per patient per month, which is acronym PMPM. So when you're talking to a practice, you'll hear a lot about, you know, we have fee for service and we have some PMPM. Most practices that are independent that are not attached to a system like, you know, a local hospital has primary care or, you know, outside of that where you're talking about, people like me who own their own practice, we are going to be, well, if you're a physician, you're going to be about 90% PMPM. So 90% of your patient practice, you're going to get a monthly fee for regardless if you see the patient. And that is the way that physicians are successful. That, whoever is not available to us as nurse practitioners, as a nurse practitioner, you, there is no insurance company that will contract you directly because you are still in a practitioner, which they consider to be a middle-level provider. So we are operating under this fee for service model and we only get paid when we see a patient. So that system of not allowing us to practice toward full potential is still, you know, these private insurance, so regardless of the state laws and the federal laws recognizing nurse practitioners as being fully economy, you know, having the DEA licenses, being able to open your own business and have this exact same employment, you know, I have the same cost. My MA costs the same as the physician now, my building costs the same as the physician now, but I can't enter into the same contracts as that physician due to my licensure and restricting because most insurance is our private companies. You know, it's take the state of glory, for instance, you know, a lot of people open their own business like well, I can play with Medicare and Medicaid. Well, there are hardly any patients in this state that have straight, Medicaid or straight Medicare. They always get picked up by a commercial insurance. So they'll have a commercially insured Medicare or they'll have a commercially insured Medicaid because the state has contracted these private companies to manage their Medicaid services. So there's this cost share of Medicaid, which is what the state has, but the patient has to pay out $1,500 a month before they can use that share. So a lot of them, you know, it really doesn't help patients. So they end up, you know, if they're eligible, they'll get into a commercial contract. And it's unfortunate that there is no regulation that says, hey, insuranceors, you have to recognize nurse practitioners. So as a nurse practitioner, we cannot contract with insurances. We have to have a physician on our pen. So that was one thing that I learned the hard way. So that's one thing as a group, you know, and I joined all the Tampa Bay Area nurse practitioner network, the Florida nurse practitioner network anything that I can join and try to get the word out there. Like, hey, we need to be lobbying somehow for these private companies to pick us up and allow us to produce, you know, what we've been trained for and what we are currently doing in practice. Once that happens, we would be able to transition to that PMP model and get higher reimbursions and probably be able to pay the nurse practitioner on an adequate salary. As far as the fee for service goes, the fee for service is basically regulated by a center for Medicare, Medicaid source of CMS. And the American Medical Association, or AMA, compromises of a physician board that creates the CPT schedule. And between the AMA and the CMS, they decide what that structure is and how much the reimbursement should be. So even if you have a straight Medicare patient, you know, I kind of feel like I'm stuck in the middle of this. I'm trying to provide the best care possible. I have the state federal government telling me what minimum wages are, what I have to pay employees, and then I also don't tell me what I get to be paid to care for patients. So there's no room. I can't charge more just because you want our money. Michael, thank you for explaining the complexity of Medicaid, Medicare, the payment system, the fee for services. You know, it definitely sounds like a challenge in a barrier for nurse practitioners to autonomously practice if you don't have that wiggle room of payment options. How do you as an NP help us as a nursing workforce? Educate the public to the value of our role or roles, depending on the person in the individual, you know, and how would you respond to somebody who doesn't understand how important they to have it is to have autonomous practice nurses to provide care? That's a great question. I think it's a very controversial question when we start comparing the NP's to the medical doctors and doctor of osteopathic medicine. I think that a lot of times though, just in practice, it is asked to at the person and not the initials behind the name. So many times I've seen that in terms of semi-whether I'm in working in the ER, in the United States, or working in private practice, or, you know, with a colleague at a seminar or conference, I find the knowledge to be very comparable. Sometimes, you know, I will know answers to the things that the ND's do not know. So, and there's times where they know what I don't know. So it's just we all have a place and we need to be working together as a team to care for patients, because the presentations are the ones that are losing by this debate, this whole controversial thing. And I think, you know, one of the biggest things in media is, you know, to be called a doctor when you go to school and you get that doctor prepared degree, can a nurse practitioner be called a doctor? You know, it's an unfortunate thing that we associated, you know, I don't know in history where we associated the doctor with a medical doctor versus, you know, just part of that doctor prepared degree. It's, you know, my life is in education, so we're funny, because we have, you know, a function, and so we like, oh, there's doctor so-and-so, well, where they're like, oh, no, that's, you know, that's a superintendent or that's, well, so what is doctor? So I think that's the public view of, when they hear that we're doctor, they're assuming that it is a, you know, person who's involved in the medical practice of medicine. And when a nurse practitioner becomes a ton of medicine, we start, I think, and I use the words practicing medicine, because, you know, by definition, we're diagnosing, prescribing, ensuring patients, and, you know, a lot of the, you know, universities don't like the saying that, because they won't say it's, it's trying to see an advanced nursing, you know, and I view it as fancy medicine, because it, in nursing is a completely different area of expertise than being a provider of fully-pomised nervous practitioner practicing medicine in a private time. So, how do we get the public to recognize that economy? I am kind of in the loss of words. I have to explain myself a lot of times in clinic, because the patients will ask, you know, are you the doctor? I thought I was seeing the doctor. Where is the doctor? Who am I going to see the doctor? It's, it's always some form, because that's what we've programmed in the United States of MD or DO, in health care. Those are the doctors and those are the ones with the most knowledge. And sometimes it does not enact your estate. And how do we expose them to what the nurse practitioner can bring to the table, and how we can improve the quality of care in the United States, and help bring in a different aspect of health care, that maybe a lot of people just really are unaware of. Michael, thank you. Your, your perspective is beautiful. And one of the things you said, I'm going to paraphrase. I wish I wrote it down. So valuable is that it depends on the individual. And our specialty and our certifications are preparing us to care for our patients. And to deliver the highest quality, safest care is what we're all trying to do as part of a health care team. So, thank you. Thank you for that perspective. Absolutely. And I think it's just, the universities have a large responsibility to help, you know, prepare those nurse practitioners for practice. And we really haven't done a lot to change the way that we educate. And this kind of falls back on what earlier conversation about that need for that residency. You know, it's one of the only industries, you know, if you talk about any type of grade school or any other type of, you know, profiting, that there's really not the need to recreate someone after they graduate with this profession. You know, if the welder goes to welding school and they get done, you can hire a welder and they're going to know how well, you know, a plumber or a teacher, you know, these, these things, they go through, you know, teachers have a clinical time, basically, too, where they go to student teaching, they graduate to teach that first year, they don't have to be trained, how to teach. So, you know, I don't know which, you know, that's kind of touching the country area because I don't really want to blame, you know, anyone, it's just a system that we've inherited and it's, you know, nurses, sometimes we're not the best with accepting change or life in change, even though we work in the, I mean, medicine changes on a daily basis. So, but I feel like that there's a need for change somewhere, whether it's pump graduate training or, you know, in actual, the nurse practitioner school, the residency programs, you know, how can we better position the nurse practitioner to be able to take on that task and that role of being a primary care provider and, and perhaps seeing medicine, and really fulfilling that need, because I, we definitely have a place and there's definitely a shortage of primary care. It's unlike anything I've seen in the history, it's the more time that goes by the less applicants we get, you know, they're, they're leaving, you know, I've had over 19 nurse practitioners work for me in the past six years and all of them that have left are doing something different, whether it's aesthetics or, you know, working at a medical practice office doing injections, like they want out of the primary care business because it is so daunting and they just weren't prepared to practice like that. And, you know, patients don't make it any easier either. I mean, I can't blame it all, you know, like one thing, but patients definitely, you know, they, they come up with their attitudes and, and, you know, you, you have to expect that. I mean, everybody's hurting, everybody's, you know, you don't know where they're at mentally, what happened to them before the visit on the car right there. I always remind people that, you know, you know, someone cut them off in traffic, they had a flat tire, whatever it is, you don't know what happened before they got to your office, so you need to be so cautiously, you know, you need to present yourself a professional manner and always treat everybody with utmost respect because I'll obviously work there for them and we're here to help the community and anything we can do, you know, to get that job done is what we're waiting for. Michael, thank you for the work that you do. Thank you. We've spoken about some pretty complex issues throughout the conversation, some heavy issues. I want to lighten it up to end our conversation, if you, if you will. So I was going to say, I'm going to end it with a couple easy questions, but as I, as I think that and they're going to come out of my mind, they're not easy questions. I don't know that I've ever really asked anybody an easy question, and that's not my intention to be so hard. It's just like the stuff that is cool to talk about, I think. So thank you. Okay, so what I wanted to say is I wanted to lobby the softball and say, underhand pitch and say, here's an easy one. With all of the experience that you have and the knowledge that you have now, would you have done anything different throughout your career? And I know that you've had previous careers before nursing and health care. So if you can focus on the health care part of your life, would you have done anything different? Or are you satisfied with the pathways that you have taken? It's tough. I don't want to take up too much time, but I'll try to shorten this story as much as I can. You know, I was kind of growing in the health care. I'm definitely an unusual egg to speak. I did not finish high school, so I have a GED, and I did a lot of grade jobs. But back in '06, my wife and I had her third child, she was born premature, 1 pound, 13 ounces. And you know, I worked, we had to go up and live in a wrong townhouse. We had to go to, you know, ICU where we were hands-on daily, and we worked with her for, you know, for seven weeks, but she was on a high frequency ventilator. It shook her so they couldn't do any imaging. They finally did some imaging for seven weeks, and they determined that she basically wasn't having brain function so that we needed to terminate support at that time. And while it is a glimpse of it, but I'm very fond of the time that I got to spend with her and the nursing staff and the doctors in that facility, the other clients, I mean, it was a life-changing experience that made me fall in love with health care. And, you know, as the time as a high school drop-out, you know, what do you do? So, you know, I joined like the local fire department. I started volunteering, I became EMT, and then that transitioned into a paramedic later. And then, eventually, I'm like, maybe I can do this, maybe I can go to school, and I, you know, I became a ER nurse, and just for, in health care for, you know, 19 years or so in the hospital system, and finally decided to go out, and try something new, and I felt like I could do more for the community, more for the people. And really, it was just an honor of my daughter, Zoe, was her name, and I think back. So, I personally wouldn't change anything because I feel like that I have helped so many people throughout the years, because of that. And I, I feel like it was just, you know, the doors were open for me that I wouldn't have never opened. So, I'm very thankful to that, I'm very thankful to care for the patients that I care for, to feel the help to people I've helped, and I personally wouldn't change my path in any way. Now, if we're strictly talking about business, I probably would not have opened my own office, it has been the most difficult thing I've ever done in my life, because the business aspects of health care that, you know, no one, no one talks about. And I will expand on that more, you know, I have my own podcast, it's medicine on court where I'm going to, you know, pop folks to speak of, of some of these insurance companies in just the way that, you know, health care works so that it's more of an open understanding for both patient provider perspective and just all around. Michael, thank you for sharing Zoe's story with us. Zoe changed your life. I'm going to try not to get emotional, sorry. Zoe changed your life in so many ways. Thank you for sharing that and letting me and the listeners of Frontline Nursing be a part of that. Amazing. Amazing how that worked for you. And thank you for also sharing and being so transparent and honest that you feel it is a privilege to be able to care for others. And that is amazing. It's hard to articulate that being a nurse when people say why do you do what you're doing or, you know, yes, nurses, I'm a nurse scientist. I want to earn a salary of other scientists, you know, but nurses don't do it for the money. We do it because of that privilege to be able to care and I think most of us are service leaders and you sound exactly like that. Yeah, it's a tough thing. You know, I think people that know me and other business owners and mentors that I've spoken with, they always ask me all the time, you know, why do you stay open? Because, you know, it's just financially, it's not good. It's not a good business to be in, as a more practitioner and honest practice. You know, I've been denied every SBA loan, I've been denied every loan. I haven't received a single penny to open my business and, you know, I have over 7,000 patients active in seven, three years in revenue, but all that revenue just goes right back out the door and costs. So, you know, and that's related to regulations and, you know, the stuff that we need to change, but until we get, you know, more people with a lot of voices, you know, we need to change some things and help here to allow us to be able to be successful on it. I'm going to, I'm going to hold on and hope that I can be one of the ones that, you know, I love change and I'll be the change maker. And it starts with one, it starts with one person. So, Michael, if our, if our listeners wanted to hear your new podcast, Medicine Uncork, where can they find that? How should they search for that? I'm on Spotify and Apple Music. Excellent. And that's Medicine Uncorked. Thanks, Ray. I want to thank Michael iPock for being a guest today on Frontline Nursing. You can find Michael's full bio and more in the show notes for this episode. I'm Raina Littorno, and this has been Frontline Nursing. Join us next episode as we continue to explore the impact nurses have on our lives and our communities. Be sure to rate, review, and follow Frontline Nursing, wherever you get your podcasts. Frontline Nursing is presented by the Florida Center for Nursing. You can learn more about the Florida Center for Nursing at the link in our show notes or by visiting flcentreforneursing.org.