Elaine Henson, NP: Entrepreneur of the Year

By Jill Rollet

When Elaine Henson began her first job as a nurse practitioner, the community of Bullhead City, Ariz., welcomed her enthusiastically. Henson had just finished the adult NP program at the University of Pennsylvania and moved west with her husband to be near his family. She easily found a position with a primary care group in the rural desert town where Arizona, Nevada and California touch.

It was 1985, and Henson expected that patients would need some convincing to see a nurse practitioner. She shouldn't have worried: "I was the only female provider in the whole county and the first female nurse practitioner. It was very busy as soon as people heard about me. Everybody wanted to come in." And they did come in – everyone from residents of surrounding Mohave County to tourists visiting casinos over the Nevada border to vacationers shooting the Colorado River.

Henson saw almost all of the practice's female patients, who were scheduled for 15-minute appointments whatever the complaint, whether established or new. She was so busy that she felt overworked and burned out after 8 months.

There must be a better way to practice, Henson thought. She recalls thinking, "'Geez, I'm a new grad here as an NP' — I was feeling kind of unsure of myself — 'but obviously I'm doing something right.' My husband was the one who suggested that I open my own practice."

Henson's practice opened in December 1986, and the nurse practitioner — with just over a year of practice under her belt — saw her first patient on Jan. 2, 1987. She still rents the original office space in Bullhead City, but it's now a satellite office where she sees 20 to 30 patients every Wednesday. The main office for Women's Medical Health Center is 60 miles away in the resort town of Lake Havasu City, where Henson lives and sees about 80 patients during three remaining 10-hour weekdays.

Marketing Superior Health Care

Henson has never had trouble attracting patients, but she works consistently to cement awareness about her. She writes newspaper and magazine articles, speaks to community groups and cosponsors health fairs. But an early ad she placed in a local phone book had a greater effect than she'd hoped for.

Shortly after her practice opened, Henson was cited by the Arizona Board of Medical Examiners for false advertising. Her half-page ad on the physicians-and-surgeons page stated at the top: "Offers Superior Health Care." Twenty-two physicians petitioned the medical board to discipline Henson for the claim. One of them was her collaborating physician, who broke off their arrangement. "I was really panicked because I knew I couldn't practice" without a collaborator, Henson adds. And because the directory was issued yearly, she couldn't change or retract the ad.

Instead, she decided to fight the charge. Audrey Rath, NP, the nurse practitioner consultant from the state board of nursing, testified at the medical board hearing on Henson's behalf. "After listening to [Rath's] defense of my practice for women, [the medical board] concluded that because of the level of time spent and teaching done consistently with each client, I did in fact provide superior care," Henson says. The medical board dismissed the false advertising charge and issued a formal apology to Henson. Her advertisements still carry the same heading today.

In the meantime, Henson found a new collaborating physician. Originally from India, the physician sympathized with Henson's situation as an outsider to an old boys' network. "He said, 'The reason I'm going to help you isn't because I'm going to get referrals from you, but because I'm a minority and I know what it's like when people put up odds against you without even knowing who you are or giving you a chance to show what you have to offer,'" Henson recalls.

Bumps in the Road

There have been other "bumps in the road," as Henson describes them, "but for the most part the medical staff in both communities [Bullhead City and Lake Havasu City] have come to respect me as an NP and admire my level of expertise."

One bump took an act of Congress to remedy. In the mid-1990s, the Centers for Medicare and Medicaid Services (CMS) reassessed the hospital in Bullhead City for urban reimbursement status. "I lost my Medicare provider number because the area I served was no longer considered rural. I could no longer care for the Medicare patients I had been seeing for years," Henson explains.

The loss of Medicare provider status negatively affected Henson's practice for 5 years, until the federal government mandated reimbursement for certain NPs regardless of geography.

But reimbursement continues to be a challenge for Henson. After 15 years of paying nurse practitioners in Arizona at 80% of the physician reimbursement rate, Blue Cross-Blue Shield (BCBS) announced 3 years ago that it would reimburse NPs at only 60%. "I was told by a key person at BCBS that their intention is to make NP solo practice obsolete — that the MDs are the preferred solo providers," Henson told ADVANCE. She took the issue to her local NP organizations, but BCBS hasn't backed down yet.

The Niche

Other changes since Henson opened her practice have been welcome. Arizona has never set geographic constraints on the NP-physician collaborative relationship, but it did require that a physician name appear on a collaboration agreement. Today, no physician name is necessary, and NPs need only to have an informal network of health care providers on board for consultation. Henson counts providers in Arizona, Nevada, California, Colorado, Utah, New Mexico and New York in her network.

One collaborator, a Phoenix surgeon specializing in gynecologic surgery, encouraged Henson to add colposcopy to her practice. She became certified in the procedure in 1990 and joined the American Society of Colposcopy and Cervical Pathology. Since then, she's continued to add to the services available in her office, without referral.

Henson's practice niche is providing comprehensive health care for women. Certified as an adult nurse practitioner, she has always made sure that women in the community know that she provides more than birth control and pelvic exams, Henson notes. About 40% of her practice is gynecology, and the rest is primary care. "I have a one-stop shop, and my patients love it," she says.

Henson has been seeing many of her patients for the entire 20 years she's owned Women's Medical Health Center. In 2002, it struck her that as her patients aged, they'd need different services, and she would be responsible for providing them.

For example, "many of my patients had become older, and I would refer them out for bone density tests and wouldn't get the reports back," Henson complains. So she bought a DEXA scanner and added bone densitometry screening to her list of services. "I can't let these people become osteoporotic and ruin their retirement," she adds.

Last year she started an in-office urometry testing program to help her patients with incontinence. "It's actually been a really large group [of patients] — those who can't finish a round of golf because they're in and out of the bathroom and their friends are getting annoyed," Henson explains. "They don't have to live that way."

Breast Cancer

One service Henson has offered from Day One is free breast exams. The annual January event attracted a slew of patients, and Henson often arranged for free mammograms. She moved the program to October when that month became Breast Cancer Awareness Month in the United States, and now she offers free breast exams year round. "I just believe that every woman should always have a way to see someone if she has a breast lump. The community knows that a breast lump is always [examined in the office] for free," Henson says.

Henson knows first-hand how important these exams can be. She was diagnosed with breast cancer in 2000 and eventually underwent two mastectomies. She kept her practice open with limited services during her nearly 2-year convalescence. At one point, she put the practice up for sale, but had no serious offers.

Today both she and her practice are healthy, and Henson believes she's become a better provider for her breast cancer patients because of her experience. She recommends genetic testing for patients with a family history of the disease, and she's an advocate for breast reconstruction for patients who choose mastectomy, no matter how old they are. "There are doctors who will say, 'Well, you're 60 years old,' and I freak out," she says.

The Next Chapter

Henson is now looking to supplement her staff of one billing specialist, two receptionists and two part-time x-ray technicians with a nurse practitioner at each of her offices. She also precepts an NP student 3 days a week and is involved in developing a new health science program at a local high school.

She sees nurse practitioner practice only getting better — for NPs and for patients. "I think the public in general has forced physicians to recognize the place that NPs have in health care. It's not through their own [physicians'] recruitment, but through patients who've had the experience of seeing an NP who say, 'I love my NP!'"

2006 Nurse Practitioner Entrepreneur of the Year Competition

ADVANCE for Nurse Practitioners is proud to announce the results of the first NP Entrepreneur of the Year competition, sponsored by ADVANCE, Resperate, NatraCare and MinuteClinic. In this section you'll meet our winner, Elaine Henson, NP, and three other nurse practitioners who have undertaken remarkable entrepreneurial ventures.

As you might guess, choosing a winner was a formidable project. The ADVANCE editorial team called on two NP business experts for help: Carolyn Buppert, NP, JD, who owns a health care law practice specializing in the concerns of NPs and physicians and who has written several books and articles on entrepreneurial and business topics, and Carolyn Zaumeyer, NP, speaker, former practice owner and author of How to Start an Independent Practice: The Nurse Practitioner's Guide to Starting a Successful Business.

ADVANCE received many outstanding submissions from nurse practitioner entrepreneurs engaged in a wide variety of practices. "I felt many times like I was comparing apples to oranges!" Zaumeyer told the team.

Submissions came from NPs with solo practices, from NPs with partners, from NPs providing primary health care, and from NPs providing specialized niche services. You'll meet many of them throughout the year in our bimonthly Practice Snapshot column.

Although both our winner and runner up practice in states with some of the most permissive laws governing NP practice, we received submissions from successful ventures in states with less ideal practice environments. In fact, before opening her practice, our honorable mention from Mississippi had to scramble to find a physician collaborator whose primary office was within 15 miles of hers.

We hope to receive equally impressive submissions next summer, when we conduct the second annual NP Entrepreneur of the Year competition. The competition isn't limited to NPs with traditional practices — we'd like to hear from NPs who have started other types of ventures as well.

As this year's winner, Henson received a $1,000 check, a commemorative plaque and other prizes from the contest sponsors. Congratulations to our winners

NP Owned and Operated

Greg Lind, NP: Runner Up

When Greg Lind, NP, earned his doctorate in nursing in 1987, he thought he would love moving from clinical practice to a teaching job at the research-oriented University of Washington. He didn't.

"It was a very challenging 2 years," Lind told ADVANCE. He found the pace of discussion slow, and he missed seeing patients. So he asked for permission to go back to practice 1 day a week.

He quickly realized why the university didn't want research faculty out in clinical practice: "because that was what I really enjoyed," Lind remembers.

Lind left the university and worked for 9 months in a clinic setting. But he soon wondered why he was working for someone else again. He knew that Washington's laws allowed nurse practitioners to own their own practices, so in the summer of 1990, he found a prime location, "I took a banker out for lunch and had a loan that afternoon."

Soon after, he opened the Lake Serene Clinic in Lynnwood, Wash. With no business background to draw from, Lind called on the expertise of local business owners and knowledgeable acquaintances. "I've since become a fairly astute businessman," Lind acknowledges.

The Vision

Washington has some of the country's most favorable laws for nurse practitioners. Since 1973, NPs have been allowed to practice almost completely independently, with no rules mandating supervision or discouraging insurance reimbursement. Today, nurse practitioners can prescribe scheduled drugs without a joint practice agreement, a formality previously required by state law.

Lind observed that although a number of NPs in the state owned their own practices, most had physician partners. Lind's goal was zero physician involvement, and his strategy was to provide a completely different kind of care.

"At that time, there were no walk-in clinics unless they were urgent care-type clinics," Lind explains. "I wanted to go back to pre-World War II practice, when there were no appointments in primary care. It was first come, first served, and you brought a chicken if you didn't have money to pay."

Although Lake Serene Clinic never took payment in livestock, it did provide walk-in primary care from 9 a.m. until 8 p.m. every day of the year, including weekends. Lind's wife would allow the clinic to open for only 5 hours on major holidays.

"There were Christmases that I had people traveling 60 miles because we were — and still are — the only clinic for some 5 million people that's open on Christmas," Lind adds. "And I had people doing physicals on Christmas because they didn't have any other day off."

Lind saw enough patients that his receipts paid all the clinic's bills and his salary only 3 months after opening.

Hospital Privileges

Lind found that his business model worked well until a patient needed to be admitted to the hospital. Although there were plenty of nurse practitioners in the state, hospital bylaws required patients to be under the care of a physician. Other NPs got their patients admitted under the name of a physician employer or partner.

The situation irked Lind because he had no access to his patients when they were in the hospital, and, perhaps worse, "there was no documentation that said that a nurse practitioner had made this assessment or saved this person's life." Lind complains, "I'd look at the discharge note, and it would say that this person just walked in off the street with a bad appendix and a doctor took care of him! I wanted some documentation that a nurse practitioner did this."

It took him 3 years, but Lind convinced the local hospital that he wasn't going to go away and that he could actually make the hospital money. He persuaded 200 physicians to support his case, and the hospital changed its bylaws to allow staff privileges for independently practicing NPs.

NP Owned and Operated

Today Lind has a nurse practitioner partner, Andrea Friesen, and they employ four other NPs, seven medical assistants, six receptionists, a CEO and two staff members for billing. The clinic is still open every day of the year, and its providers are available by phone 24 hours a day. They still see walk-in patients, but they also offer appointments to approximately 350 patients a week. Lake Serene Clinic saw 15,000 patients and billed more than $2 million in services this year.

Lind and Friesen offer their NPs profit sharing and productivity increases, and provide bonuses for other staff members based on initiative, critical thinking and hard work.

– Jill Rollet

Don't Try This at Home

KC Arnold, NP: Honorable Mention

Nurse practitioner KC Arnold's clinic was born of disaster. When Hurricane Katrina hit Ocean Springs, Miss., in August 2005, Arnold evacuated with the rest of the city. Returning a few days later to volunteer at a Red Cross shelter, she reopened the office where she worked, a physician-owned satellite endocrinology center, even though the other staff members weren't able to return. Six weeks after the storm, her employer decided to permenently close the clinic.

Out of a job and yearning to help her neighbors who'd lost continuity of care, as well as their community as they knew it, Arnold made a decision: She would open her own practice. Even before the damage to her own house was repaired, Arnold found a local physician to be her legal collaborator, located office space and free equipment, and signed papers for a $30,000 business loan and a $25,000 computer loan.

On Nov. 1, 2005, The Diabetes Center opened. In the months that followed, the practice was a lifesaver for patients on insulin who needed supplies and someone to manage their pumps. Medtronic sent extra supplies to Arnold and listed The Diabetes Center on its Web site as a local emergency supplier; the U.S. Postal Service and overnight delivery companies weren't yet reaching homes in the area.

"Patients got my number from the Internet or just by word of mouth," Arnold recalls. "One day I was out raking debris, and a policeman saw me. He knew I treated diabetes and had supplies, and he had somebody who needed help. She was able to get to my office. She wasn't even my patient at the time, but she is now."

Arnold is certain that if the hurricane had spared Ocean Springs, she wouldn't be a practice owner today. "I would have just stayed where I was," she admits. "But now that I have my own practice, I wouldn't want it any other way."

Arnold still sees about 90% of her former patients – they're the ones who've stayed in the area. And since her former clinic is open just 1 day a week and another endocrinologist has left the area, she's had no problem attracting new patients. "I have a special niche in this community, and it's really helped my business," Arnold told ADVANCE.

Earlier this year, Arnold was honored by MSNBC's dLife, a multimedia information source for people with diabetes. She was named one of the top 10 people making a difference in diabetes. "The faces of the patients who saw the announcement and were so proud of me was worth more than anything," Arnold says. "As a new small business owner, this was the most amazing advertising I could ever hope for."

Arnold doesn't recommend launching a new business in the wake of disaster with only 3 weeks of planning. But she admits that it worked for her. Her greatest challenge has been insurance credentialling, with several self-funded compainies refusing to recognize independent NPs.

Arnold paid off her original loan within the first year, and she's beginning to think of The Diabetes Center as a typical business. "I'm here and financially viable, and I feel proud of the care my staff and I provide for patients."

–Jill Rollet

True Grit

Scharmaine Lawson, NP: Honorable Mention

In March 2005, family nurse practitioner Scharmaine Lawson launched Advanced Clinical Consultants in the carriage house behind her uptown New Orleans home. The business concept was to provide home health care visits to older adults and patients with disabilities who lived in the heart of the city.

Lawson had pitched the concept to her physician employer, but he passed on the idea, and she decided she was ready to strike out on her own. In just 3 months, she more than tripled her caseload, and physicians and home health agencies were calling her to see their patients.

"It was a little overwhelming because it was so unsolicited — it was like someone gave me a big gift," Lawson says. "It's what I always really wanted to do — to provide care not just to the elderly, but particularly to indigent patients. I wanted to make a difference." Soon after she opened, she was able to cover all expenses with her income from Medicare reimbursements and other third-party payers.

Then Hurricane Katrina landed, and the city's levees cracked. "We lost everything," Lawson remembers, referring to herself and her office manager. "We lost our building, our patients, our medical records — just everything."

Luckily, Lawson took her computer and her PDA when she evacuated. She was able to get back to work immediately when she returned to New Orleans in October 2005. "I was able to recapture some data," Lawson says, "but most of the population was either dead or relocated to another state. We were able to bounce back rather quickly because the city's health care system had been totally devastated."

Lawson found herself practically alone providing care to sick, traumatized and homeless patients. Where other resources had fled the area, she was willing to go anywhere to make a house call.

"A lot of our clients are still living in homes that sustained substantial storm damage," Lawson said during an interview in October. "The homes are infested with roaches and other creatures, and in some cases the floors are open to the ground because [the owners] are unable to afford repairs."

Lawson's first priority is making sure her clients are safe. She often serves as social worker as much as health care provider, helping patients navigate relief agency paperwork, signing them up for Meals on Wheels, coming up with a FEMA trailer, calling for hospice. In addition to providing any needed primary care, she arranges for same-day visits with podiatrists, ophthalmologists, pharmacies and any other professionals her patients should see.

Lawson now has as many patients as she can handle, but not having the heart to say no, she adds more each day. Visiting a client often reveals two or three others in the same home. At her clinic days at rural churches, she tends to focus on diabetes care and Medicare Part D education.

"I need a clone," Lawson acknowledges. "I never thought I'd be performing Third World work in my own neighborhood."

Lawson is already percolating plans for her next business venture — providing housing for older adults.

– Jill Rollet