The 2009 Nurse Practitioner Entrepreneur of the Year - family NP Teri Bunker - knows that size matters. After 5 years of running Bridge City Family Medical Clinic out of a small office in Portland, Ore., she bought and renovated a larger building last summer. She now owns 5,000 square feet of office space that includes a kitchen and a gym. This expansion allowed her to supplement her staff, which now includes three physicians, two family nurse practitioners and a personal trainer. The clinic's patient roster is now a robust 350 per week, prompting Bunker to make grander plans.
Along with this growth, Bunker's anxiety has expanded. "It was less scary to start out than to grow to where I am now," she acknowledges. "I have 11 employees, and I'm hiring more - and they're buying houses based on the job they have. That's a lot of responsibility."
Five years after graduating from her NP program, in 2003, Bunker was working for the Clackamas County (Oregon) Health Department and not loving it. She could find another job, but she doubted it would be one she'd want to stick with. What she really wanted, she realized, was to be the boss.
Bunker mentioned her idea to her partner, who said, "Why don't you just do it? What's the worst that could happen?" With that little push, Bunker determined that it was financially feasible. Her student loans were paid off, and the couple was able to take out a home equity loan. "Cindy told me not to worry as $75,000 was a small price for a dream, and she was confident I was going to be successful," Bunker says.
But the practical aspects of opening an NP practice were harder to manage. Bunker had heard that practice laws in Oregon favored independent practice and business ownership for nurse practitioners. But when she looked for a mentor in the Portland area, she found no one. She queried her former professors, and they couldn't help her connect with anyone running a practice like the one she envisioned.
The NP practices she found didn't compete with physician offices. They were rural or catered to the uninsured - niches traditionally shunned by physicians. Bunker wanted an office in the city, and she wanted to make money at it. Her lack of role models made her think twice: "When you don't see people around you doing it, it's scary. What makes me think I can do it?"
So she ran the numbers. Bunker's business model targeted Medicaid patients. Oregon was experiencing budget problems and had cut funding to its Medicaid program. Like other states, Oregon paid private insurance companies to administer its public program. When the state cut funding, the insurance companies slashed reimbursement rates. In response, many healthcare providers dropped their contracts and would no longer accept Medicaid patients - leaving thousands of patients with no place to go.
Bunker's plan was to take on these patients. After her position with the health department, she knew the challenges of working with this population and was comfortable caring for them. With the lower reimbursement rates, she knew she'd have to see more Medicaid patients than she would if her patients had commercial insurance. Her plan was simply to work harder and smarter than the next guy.
The model worked for Bunker, and her patient roster grew quickly. Based on her success, last year she was able to negotiate a large capitated contract with a Medicaid insurer, which she hopes will open the door to such contracts with other insurers as well. Under a capitated plan, the insurance company guarantees a certain number of patients per year at a certain monthly payment per patient. Bunker handles all their primary care. The more patients in the plan, the more the risk is spread: High utilizers are balanced by healthy patients who seldom need to be seen.