Researching Switching Gears to HHC - Entrepreneural Route

NancyRN · Nov 22, 2002

Nightngale, this sounds so nice! I'm afraid of the paperwork too. I can't wait to see what others have to say. I'm ready to try doing home visits for those who just want to pay on a per visit basis.

LoisJean · Nov 23, 2002

Greetings!

I listened with great interest the report on the CBS Nightly News tonight of the small, but growing number of physicians who are no longer doing insurance billing for the patients they see in their offices-- (The doctors professional fees). These doctors have found that by chargeing a flat fee to each patient who comes in they save $1000s in overhead. A Mississippi doc charges a flat fee of $40.00 per patient per office call. Of course all tests, etc are covered by insurance. The point is that by eliminating this part of the paper work, the business saves time and $$ in the long run and the physician actually comes out ahead profit wise, because he is not waiting for a watered down check from Medicare/caid or other health care providers--the deal is cash payment at time of service. I am willing to bet that these are the docs who operate small clinics with minimal staff... just like a self-employed person who has little, if any, resources to keep them viable over the long haul.

I do not believe that the self-employed nurse acting as a sub-contractor for an Agency, institution or physician is the one to be doing the insurance billing if her work is billable. It is the responsiblity of the Primary Agent(cy) who is requesting the services of the contractor. These are the people who pay other people to do the billing. Believe me, if I had to do the billing for my Medicaid clients, it would be reflected as an additional charge to my fee for services--a whopping big charge, it would be, too!

The problem for the entrepreneural nurse is start up costs and making some kind of living wage while getting her business onto it's feet. It is uncommon for anyone to be able to start their own grass roots business without having to work a 'real' job at the same time. So, in most cases, we use our 'spare' time to build up our businesses while working for someone else.

I knew that the work I wanted to do would not be covered by any health insurance provider because it is not considered a 'skilled' care when provided by a nurse--it is considered skilled when performed by a podiatrist. Well,--I knew that the demand for the type of nursing service I could provide was high-and that people would be willing to pay out of their pockets for it IF it was a fair and reasonable charge. By calculating the initial outlay for the supplies I would need and factoring in the size of the territory I was willing to cover, I saw that I could more than likely make more money on my own than I was making working for an Agency. #1: I could control my territory-decreasing mileage and car maintenence expenses; #2: I could control supply costs; #3: I could put 10% of my earnings into a savngs account, letting it earn interest and put the rest into my household to help with bills, food, etc; #4: I knew that everything, everything, everything which reflected back onto the business was deductable--even the laundry soap I used to wash my work clothes. I also knew that I would show a loss at tax time- that loss coupled with my deductions would give me money back from Uncle Sam.

I also knew that the people who used my services were telling other people about my services and so those people wanted my services and people they knew wanted my services and so on, and so on, and so on. Word of mouth saved me a bundle in advertising. There is much more I can tell you about how my business grew, but will save it for another post perhaps.

I think that people will pay for convenience--especially if it is unique and offered in the home setting. I think that if a nurse has a PARTICULAR skill that she can provide ALONG with other cares-or whatever it is she feels she wants her business to be primarily-she will have a foot in the door of successful self-employment.

What I want to read in these posts is what are you are thinking about as far as self-employment? What is it you want to do as a self employed person? Describe the venture. Even if it's only an idea at this stage.

It takes a particular type of person to wing it alone...it takes an independent spirit, a trust in ones own skills and a deep desire to be free of the one thousand entanglements that prevent a nurse from providing the care she truly wants to give people--to be able to practice her science and art as a free agent...to be as unencumbered from bureauacratic clutter as possible.

I cannot believe that out of all the nurses posting on this BB, that only a handful have considered self-employment as a professional career option. But, we shall see as time goes by--it is vital that I hear from all of you...because, for a long time I have felt that certainly I AM the only independent out here...and frankly, it's been damn lonely. So there, I've said something! D

Peace,

Lois Jean:

nightingale, RN · Nov 23, 2002

Dang Lois Jean... you spoke of being valued in our work. How little I feel of that now as an Agency Nurse. Yes, there is a bit of it here and there but...

When I did wound care before in the home setting I loved that. I was in a high learning curve. I was not fully trained and did have to consult the WC Specialist regularly. I know there are Wound Care Certifications etc.

I have the ability to subcontract to the Agency I spoke of to "Start". That is a blessing. So far price has not been negotiated so that is a big "if".

I may actually get a travel contract to supplement my income for 13 weeks etc. That would totally free me up on, oh, 4 days a week.

It is great that you researched the market first before venturing out. Foot Care is such a big need of the elderly. Additionally, Diabetic Foot Care is vital in avoiding foot ulcers and subsequent amputations. I see that as a need in any community. Quite frankly, I do not know if I will be good at that or have a talent in that specialty.

Another colleague I spoke to about this suggested they might volounteer at a senior center to provide these services free of charge. Coincidently, my senior work at a University did just that but would not generally treat diabetics (what a loss for the community). The instructor sited liability etc.

Quite frankly, I love to treat the elderly. I find them so much fun to listen to. Providing information of teaching meds, patho. of disease processes, was always so valued by them. Maybe I was lucky and had an unusually astute population. All of my clients were willing to help themselves too.

So for doing what I like? hmmm.... I will have to challenge myself on that one.

There are unmet needs of the community that I would like to fill. From a business perspective, that is my approach. It has been such a long time since I was able to go around the table and ask myself, "What services do I like to perform"?

I KNOW there are more then the two of us. Let's here from YOU!

B.

PS.. I posted tha article mentioned by Lois Jean on another thread here at the Entrepreneural Forum titiled, "Doctor and Nurse At Your Door".

nightingale, RN · Nov 27, 2002

Well?

sunnygirl272 · Nov 27, 2002

i have often not-entirely joked that we should make a mobile unit for dressing changes, private pay, for the clients that do not have family/friends that are reliable enough to be counted on to do dressings...and yet the clients fall through the cracks..are not eligible for home care for various reasons....

nightingale, RN · Nov 29, 2002

Sunnygirl:

I agree there is probably a need for the service. What I would love to see are more services available directly by nurses who can access those clients dirctly.

It slays me that WE do the work, meidcare bills, and the "middle man is the BIG profitable margin.

I actually had a manager (who I subcontract with through my business at a facility) tell me, I can't allow you to make more then what I make! Uh... but why?

I have worked 10 years towards my colleage education.

I am still paying on my school loans.

I put MY license on the line every day to meet patient needs.

Without ME, that particular patient care billable service, would not exist.

I am the one who goes home exhausted, needing to disinfect, stay abreast of new infornation/education to provide the highest quality healthcare for my patients.

I love my profession. BUT WHY should I not be compensated appropriately.. instead of the manager?

I am capable of managing myself... thank you.. may I cut out the middle man sometime soon? I hope so... cause I am tired of not really being successful and profitable....

LoisJean · Nov 30, 2002

Sunnygirl and Bonnie;

Precisely so. Sunnygirl, your thought regarding a mobile unit for providing in-home site dressing changes is an excellent one. I cannot tell you how often I go into a home to provide foot care and ended up doing a dressing change, too, because there was no one else to do it. In most cases these are elderly folks who either live alone or there elderly mate is unable to perform the procedure. I have had elderly people admitted to nursing homes because they have exhausted HHC services--most of these folks don't need a nursing home--they need home care nursing services. They simply could not respond to a HHC nurse's ministrations in the time alloted to them...

There has got to be a way to get well motiviated, self employed nurses into a home care setting and be reimbursed by health care insurers for care delivered. It seems to me that docs would be falling all over themselves to get such care to their patients--willing to sponsor or contract independent nurses to provide care in such a manner for their patients who need assistance beyond what HHC agencies can provide. And it seems to me that these docs would be more than willing to run the billing through their own offices.

And, Bonnie is right. In order for a business to be successful there can only be one manager--and that is the person who owns the business. Self employment is attractive to many people precisely because of the autonomy it offers. When a business owner provides a service that is attractive to a consumer, it is not the place of anyone else to decide what the fee for service should be based on...the consumer is the one who decides what is fair or else he won't participate in the service being offered.

Now I know that when I worked in HHC, the insurer was charged $110.00 for each of my visits; I was paid $18.00 for each visit. There is something really wrong with that number, in my opinion.

I knew that I could work independently, make a living, pay my bills and maintain my business on far less than $110.00 per client. I knew that I could provide a better service and that my service could not ever be discontinued unless the client expressed that desire directly to me. I knew that I could control my out-go as well as my in-come. And I also knew that I would make a profit- that my hard work was not going to pad the pocket of strangers who had no concept of what my knowledge and expertise entailed; people who cared less about the work I do, but cared more that my work bought them a profit margin.

There are so many facets to home care nursing that I truly believe that those of us who want the independence of self-employment, have the knowledge and expertise to provide skilled cares, can find a myriad of services to offer to people who no longer qualify for nursing care in the home. And because we can provide that care FOR LESS than what an agency or other clinical setting would charge, it seems to me that we would be looked upon with great interest by insurers like Medicare who are loath to fully reimburse for increased charges--thus creating cuts in insurable cares--it's in the area of these cuts where we would fill the gap.

The question to all nurses who have a pull/tug/desire to go independent is- what gap would you fill? Where do you see a need that is no longer being provided for?

Peace,

Lois Jean

kae rn · Dec 1, 2002

Would so love to be totally independent as a nurse. My area that I enjoy is caring for med frag children private duty. Have applied and received my independent provider number in my state and can bill directly without an agency getting the profit. Problem is: the politics. Jobs are hard to find because most parents are utilizing the agencies. I think as a parent, I would rather pick each individual person who comes into my home and manage them myself. But, I think parents are overwhelmed and take the easier path, or perhaps don't even know about their options. Plan to keep plugging away, working a variety of jobs and building my client list. Probably a few years or so done the road, but doable. Nothing ever happens overnight.

kae

nightingale, RN · Dec 1, 2002

Kae: Are there an waiver programs that would suit your patient needs?

I can not imagine how to market your services; but I am sure there is a way. Maybe others will have feedback?

I am completing a samll business class that is sanctioned by the local Chamber of Commerce on Entrepreneurship. Perhaps you might be interested in what is going on in your area for puting together a business plan and it willl include marketing.

I wish you well in whatever you decide. Please let us know how you are doing,

B.

Agnus · Dec 18, 2002

My concern in launching a business is I live in a very economically depressed area. Were I still living in Sacramento this would not be a problem. Charging a fee without using medicare/medicaid might not be a profitable enterprise in this area.

I know many people here would rather go without necesities than to pay for them even when they have the means. It is a terrible poverty mindset.

There is also little motivation to take responsibility for ones own health here. Education is low. Our dropp out rate is one of the worst in the nation and is the worst in the state. Only 2% who actually get to the point of entering community college (locally) graduate.

I want to provide direct sservice and particularly direct teaching but there has to be a market. This is scary.

nightingale, RN · Dec 18, 2002

So Agnus.. don't quite your day job and proceed slowly. Lois Jean found her nitch. I know there are many markets

If it is too scary then don't do it; if it is rewarding then try it.