AHLA's Speaking of Health Law
The American Health Law Association (AHLA) is the largest nonprofit, nonpartisan educational organization devoted to legal issues in the health care field. AHLA's Speaking of Health Law podcasts offer thoughtful analysis and insightful commentary on the legal and policy issues affecting the American health care system.
AHLA's Speaking of Health Law
Advanced Practice Providers: Latest Trends and Developments
The growth of advanced practice providers (APPs) continues to transform the provider landscape. Joe Aguilar, Managing Partner, HMS Valuation Partners, Alaina Crislip, Member, Jackson Kelly PLLC, and Emily Grey, Partner, Breazeale Sachse & Wilson LLP, share their observations about how APPs are evolving, with a focus on issues related to billing and innovation. Joe, Alaina, and Emily spoke about this topic on a recent AHLA webinar. Sponsored by HMS Valuation Partners.
Watch this episode: https://www.youtube.com/watch?v=Tawbejwnc-g
Learn more about HMS Valuation Partners: https://hmsvalue.com/
Learn more about the AHLA webinar, “The Future of Providing Care with Advanced Practice Providers - New Market Models and Challenges”: https://educate.americanhealthlaw.org/local/catalog/view/product.php?productid=1651
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Learn more about AHLA and the educational resources available to the health law community at https://www.americanhealthlaw.org/.
This episode of AHLA Speaking of Health Law is sponsored by HMS Valuation Partners. For more information, visit HMSvalue.com.
SPEAKER_00:Welcome everyone to this episode of AHLA's Speaking of Health Law podcast. I am very excited today for this episode on all things APP or advanced practice providers with my colleagues Alina Chrislip and Emily Gray. We had so much fun with this topic just last month on a webinar that we thought we'd take the show on the road and have even further conversation today. With that, my name is Joe Aguilar. I am the managing partner with HMS Valuation Partners and have focused my 30 plus years on physician and APP compensation along with fair market value and commercial reasonless work. With that, I'll pass it to my colleagues to introduce themselves. And I guess we'll start with Elena.
SPEAKER_02:Thanks, Joe. Elena Chrislip. I'm a healthcare regulatory compliance lawyer, sort of the general practitioner of healthcare law here in uh Charleston, West Virginia at Jackson Kelly PLLC.
SPEAKER_04:And I am Emily Gray, and like Elena, I have kind of a broad regulatory practice. I'm located in Baton Rouge, Louisiana, where I am a partner at Brazil, Saxe and Wilson, and I'm on the firm's management committee. And in my 25 years, I've represented a variety of healthcare providers of all shapes and sizes.
SPEAKER_00:All right. Well, I think as I think back when we first started connecting on this, because we actually talked on or presented, I should say, in February with the advising providers conference. What struck me to on this topic was just the continued use of APPs. As a nurse practitioner myself, which I started 20 plus years ago, it was primarily just a few specialties, and now they they seem to be integrated into not only the specialties, but even the subspecialties. MGMA just recently uh put out a poll and which uh asked medical groups what percentage of the um of them were thinking about adding new APP positions, and it was over 65 percent, um, which I I I find remarkable just thinking back you know 20 plus years ago as a student. But um that obviously has led to um the I guess the legal profession and compliance folks to figure out ways to do it right um and avoid um any any pitfalls. I guess um I'll I'll leave it uh give it up to you, Elena or or Elena, sorry, or um or Emily uh as to um you know how how do you see that growth impacting um what you're seeing on a day-to-day basis with APPs and your clients.
SPEAKER_04:I'll jump in real quickly. One of the things I was thinking, Joe, as you were speaking, is that part of the evolution we're seeing is kind of the evolution in our overall population, right? As we have, you know, kind of our a number of physicians, kind of a silver tsunami aging out, um, looking at using our resources wisely and extending physicians as best we can with APPs, I think makes a real difference in the healthcare space and the delivery of care. And I think that's perhaps part of why we're seeing, you know, the the increase in the numbers, um, and just that it works.
SPEAKER_02:I I would agree with that. I I also don't know, you know, because of I still feel like things are still backed up because of the the COVID, the public health emergency. We still have a lot of backlogs with physicians, and you know, if you can't multiply yourself, how how do you extend yourself, right? And the use of APPs both in hospital settings and and outpatient settings, I think is helping, you know, to to address and make sure that physicians um are meeting and and seeing all of their patients to the extent that they can.
SPEAKER_04:And I think patients are more comfortable with APPs now than they were maybe 10 or 20 years ago. Um you know, I think about my parents who were more like, I want to see the doctor, um, as opposed to folks who are really happy with the level of access and the level of care that's provided with APPs more now.
SPEAKER_00:I mean, I think that that certainly resonates with me because um 20, 22, 23 years ago, um the concept of the nurse practitioner even mentioning that I was going back to school uh to Hopkins to seek this degree uh just was um not really understood by the general public. And now you're seeing nurse practitioners in the commercials, uh, you're seeing um shoot even hitting the big time with Netflix, uh, what's that series, Virgin River, uh, with their with their lead uh lead um heroine uh as a nurse practitioner. But um but no, I I I agree. What's what's what's been interesting in this is I I've been able to get the opportunity to talk with provider compensation specialists across the country, and they brought together a panel of APPs that are actually certified in rheumatology, in neurology, and all these sub-specializations, and they're being certified in that manner because um organizations are put putting together fellowships um for APPs as well. So I it's it it's just changed the landscape tremendously.
SPEAKER_02:I I don't think we should lose sight either, Joe, and and you probably know this better than anybody that in in a lot of states, a majority of states, nurse practitioners can hang up their own shingle as well. And so, you know, to the extent we start getting into some of these billing rules, nurse practitioners based on state law can also delegate, right, and and be functioning uh in in that role where they're delegating to others. So I I think that's kind of an important point as well, that they can themselves hold up their own shingle um depending on the state law involved.
SPEAKER_04:That is so true, Elena. Um, and in you know, our presentations, I was kind of focused on the state law. And even in a matter of six months, there were changes where, you know, Arkansas, for example, I had to go back and make updates because they allowed autonomous practice for their NPs and just changed the law very quickly. And I think that's a trend that we're seeing in the states. I think, you know, with this increase in comfort with the APPs, we're seeing states give them, you know, kind of broader authority.
SPEAKER_02:And I think, Emily, too, and Joe, maybe you can speak to this. I mean, there is a workforce shortage, right, from the healthcare perspective generally, and that might also be, you know, uh one of the impetuses for for states wanting these folks to have more autonomous ability to operate on their own to help address the workforce shortage.
SPEAKER_00:I completely agree. I I I I think um, and this is probably a topic for another podcast, but even the idea of training APPs um and how are they trained, um, what type of um clinical experience do they have while they're in school? Is there a role for even a residency program for APPs in the future with so many residency spots going unmatched, as well as you know, communities not necessarily being fully serviced? So I I think there's a lot that I uh you know, what is our topic called? Charting the future. I I I think there's a lot of pathways for the future of APP practice, there's there's no doubt. And I also think it makes sense just from the models uh you know standpoint, um, you know, when you think about primary care uh and and your first new appointment is three weeks out, uh it that just doesn't make sense that you don't have advanced practice providers being able to see that patient because they can handle the vast majority of primary care within the scope. Um and then when you think about the um subspecialties like you know neurology or endocrinology, there's a lot of ways that they can extend um, or even the surgical practices where they're dealing with follow-up or or pre-surgery assessments. Um there's lots of ways that they can um really facilitate the care of more more patients as as as um we mentioned. But I I guess and this has been an issue for us uh for me ever since I was uh a new NP, is all the billing nuances um that arise with this. Um I mean what do you all see as some of the challenges there to keep you know health systems as their employers or APPs in general um on the straight and narrow with regards to billing?
SPEAKER_02:Yeah, so I mean that's a that's a great point. I mean, short of direct billing, right? And and making sure that you know you're meeting medical necessity and billing under the practitioner, either the physician or or other APPs own MPI number, you're there are you know incident two and outpatient settings, um, and then there's split shared and institutional settings. And I think that you know it's critical compliance for for meeting these um billing rules is is important for for entities and making sure that you have the appropriate documentation, reflecting that you're meeting all of the specific rules involved with with each of the types of billing rules.
SPEAKER_00:Yeah, no, I mean I I think do do y'all find um are y'all getting a lot of questions on that subject as as health systems dive into more and more use of APPs?
SPEAKER_04:I'm not seeing so much questions with the billing requirements as I am, you know, and I'm just thinking this week we saw some questions um for a provider who has, you know, the physician was out on vacation and then saw an unusual number of patients, you know, using his NPs. And I think there is some scrutiny there, um, and you have to be real careful about the billing um and and how you're handling it, particularly with you know, if you're trying to do a high volume of patients uh under a single supervision supervising physician.
SPEAKER_00:Yeah, that I mean I that's an interesting comment because we've seen um a couple of situations where, and again, this is state by state um driven, but where a single physician may be supervising three or upwards of ten or more APPs, and you know, what's what's okay, what's not okay, even beyond what the state regs say in the moment.
SPEAKER_02:Um and I would argue to show that you're you're you're when you're billing, you're saying you're meeting all the billing requirements and all requirements under state law. So if you're supervising more APPs than maybe you should be, I think there's an open question as to whether or not you've been actually meeting all the requirements to bill, um, depending on how you bill those services. So um I don't know, Emily. I know that you in your presentation you gave a lot of like the specifics from state to state as to how many, you know, APPs a physician could could oversee. So I don't know if you have any other thoughts on that. Yes, y'all lined that up for me perfectly.
SPEAKER_04:Um thank you. That's my cue. Um, really, one of the things that's that's critical when you're setting these up is making sure that you're familiar with what the state law requires. Um, there are tremendous variances in supervision ratios state by state. Um, some states like Arizona and Colorado don't require any physician supervision. Um other states have aggregate limits. So, you know, in looking at some of these, and I gave a laundry list of states and requirements in the presentation. Um, but they're, you know, if you've seen one state, you've kind of seen one state. South Carolina has a limit of six in the aggregate, NPs are PAs. Alabama has a limit for physicians that can only supervise up to 360 hours per week, which are nine FTEs of NPs and PAs. Some have limits on PAs, but not NPs, like in Delaware, physicians can collaborate with four PAs and no limit on NPs. Louisiana, my state, uh a physician, there's no limit on NPs. That limit was removed, gosh, probably 10 years ago. But there's a limit of eight PAs. Um, and then some states require you to have backup physicians in addition to that one supervising physician. So there is a lot of variance.
SPEAKER_00:Yeah, and so thinking about supervision, so at when I practiced, um I I had uh the pleasure of actually having a separate clinic where I was connected to my um collaborating physician telephonically. So if there was a need, they you know, I I could call them. Um but I know that you know with incident two and other and other type of billing rules, there's kind of certain restrictions or regulatory requirements to meet those rules. I think uh Elena, you spoke on some of those, um, even specific to like location of the physician.
SPEAKER_02:Yeah. So for for incident two requirements, the um incident two billing requirements or billing rule, you know, the physician has to uh provide direct supervision to the um the provider that they are are um billing the service incident to. I did want to clarify that it can't, you know, it's a patient if you're if it's incident to the physician, right? It's a patient that's already come in that the physician seen developed a treatment plan for, and the the APP is is reviewing the plan of care and you know, just evaluating the patient consistent with what uh the physician has already developed. And so as far as the direct supervision, they have to be present in the office suite and immediately available to furnish assistance. And so depending on the Mac involved, if there's any questions, you know, you can have a discussion with your Mac, but it's also sort of a common sense type approach. Um, if you have a suite on the first floor and you also have a suite on the third floor, you know, and your physician's on the third floor and your APP's on the first floor, that's probably not really direct supervision. Um, I think there's even a question, depending on the Mac, if you have an L-shaped suite and the physicians at one end and the APP's at the other, and you can't really, they can't hear you, right? Unless you have some sort of telecommunication or um intercom system in the in the suite, that there might be a question as to whether or not that is actually direct supervision. And so they have to be available for questions. Short bio breaks are okay, but I mean, if they're otherwise involved involved in in treating another patient or in the middle of a procedure and wouldn't be available, I think there's a question of whether or not they're meeting direct supervision. And and kind of going back to the compliance uh part you mentioned earlier, Joe, is I think that the the doctor should document, right, in the record who was the, you know, or the APP, who was the physician or or the person who was providing um the direct supervision for the incident two service to be billed.
SPEAKER_04:The devil really is in the details. I mean, it seems so persnickety for the health lawyers to say, okay, it matters if your building is L-shaped or if you're on the second floor or the first floor with your NP. It's um uh remarkable how how detailed and careful they have to be. And if you multiply a problem by a year or two years, um, it starts adding up to be a really expensive problem potentially.
SPEAKER_00:I agree. I I I I just out of curiosity, I mean, uh do y'all are y'all seeing incident two questions more prevalent with your hospital health system clients versus your private medical groups? Um and the only reason I ask is because we're we're seeing a lot of health systems seem to want to move the way of direct billing and not necessarily using the NPI number of the APPs. And but yet when you've got these medical groups that either uh joint venture or become acquired, um which they still are, it's still happening, um, you see the medical groups being more comfortable billing incident two. Um no doubt avoidance of the 85% reduction or 85% reimbursement rate. But just curious if if you guys are seeing any particular type of clients for this question.
SPEAKER_02:To move to the to to try to uh obtain the maximum amount of reimbursement. Yeah, I think I think that's always you know on on the you know a matter of evaluation in a business decision, right? Because as we we've pointed out here and in our uh webinar, there are compliance risks associated if you're not meeting the billing requirements. And so especially um, you know, there can be some substantial paybacks with with both shared, you know, split shared um billing and incident two billing. And so I do, I do think to your first point there, Joe, you're seeing a lot of folks say, well, it's not worth the headache. We know operationally we're not gonna document the requirements to meet this if we're ever audited. Um, so we're just gonna direct bill, right? To the extent that our physician, our nurse practitioner, our folks can direct bill, we're gonna just have them bill under their MPI numbers and we're willing to take that 85% reimbursement versus the 100%, you know, the physician fee schedule because, you know, we can sleep better at night knowing that we don't have these open compliance risks that we need to be auditing for.
SPEAKER_00:Yeah, yeah.
SPEAKER_04:Well, and uh my experience is is similar. And I think when I look at you know, my practice, we get more questions from medical groups, um, and they seem often more willing to uh push the envelope, perhaps, uh, than some of the health systems. Um, and you know, they may have less questions, or I think they have less questions because probably they're more sophisticated and more risk-averse.
SPEAKER_00:Yeah.
SPEAKER_04:Um so that that's been what I've seen.
SPEAKER_00:And I think that it lends itself better to certain specialties and certain models where the APPs are working. So, like if you're primary care and trying to do incident two, that's super hard. I mean, Mrs. Jones comes in for a follow-up on her diabetes, and and the diabetes may be the initial diagnosis that you're down billing the incident two follow-up care on, but she's got a cold. And now you're what are you gonna do? Like, well, sorry, you can't see me for the cold. Uh, you know, and there are there are ways you can do it, but it requires a lot of you know jumping through hoops. But if I am um you know working as the diabetes educator at in an endocrinology practice, and my patients are pretty you know routinely coming in for just their diabetes care, I mean, then it makes complete sense to try to set up a system that allows you to bill, you know, instant two under the guise of following at least that component of the rule. But um, yeah, it it's it that that that's always been interesting ever since I started practicing and how how to how to navigate that just as an NP.
SPEAKER_02:Yeah, and I I was just envisioning and again, I'm not I'm not a technological person myself, but I'm thinking that technologically there's got to be something that I was thinking through in an EMR system, for example, right? If they're coming in for their diabetes and you're putting in an additional diagnosis, in my mind that should send off bells and whistles, right? Or or or flag that in some way for your billing folks to know that's a new, that they're coming in for a new condition, right? And so this should not be build incident too. And I'm thinking in discussions with EMR uh vendors, there's got to be a way maybe to flag that even internally so your your folks on the billing side would know that's gotta be billed differently and can't be build incident to.
SPEAKER_00:Yeah, agreed. I'm not sure if that's that that's in place.
SPEAKER_02:Um I don't know, but hopefully a vendor out there after hearing this will put it in place.
SPEAKER_00:I know a few of them. I I should have that conversation with them. Well, I and and I'm not gonna I'm gonna try to switch gears uh a little bit and we'll just keep the conversation rolling. But um, you know, you mentioned, Elena, that NPs are able to hang their own shingle on things. Um, and it doesn't always have to be in that capacity. But I know, Emily, you spoke on on the webinar as well as the the um the presentation we did at the conference up on innovative ways of using APPs, and that you know, you're often hit with kind of first-time questions of, hey, can we do this? Um maybe you can shed a little light on how you approach those questions.
SPEAKER_04:Sure. And you know, that's really been um fascinating and fun, and you get to be a little creative, I guess. Um one of the things that I've seen in the last few years are some entrepreneur types um who are looking to establish you know virtual clinics without brick and mortar, uh, which is something I think, again, as we've seen the evolution of you know, healthcare, we see folks much more comfortable with telehealth, much less need of having an office. I think that's something that the pandemic brought to us. Everybody learned uh how to do Zoom. Um so what we're seeing is um you know providers taking advantage of this and looking for ways uh to bring care to people in their homes, not to have to have bricks and mortar. Um I see folks coming in wanting to do things across state borders in different states. Often they come to me and say, I have this idea, let's start it here, but we want to set it up in a way that we can go national, right? And so what do we look at first when we do that? Um, if we're working with in-house counsel, I give them a little bit of guidance. And if I'm working directly with the business people, um, you know, I do my best to help them put on the brakes a little bit sometimes. Um the business folks seem to be very eager and quick. I had one group that thought, you know, as long as I get authorized to do business in the state, we can pretty much do whatever we want, right? It's like, whoa, you know, slow down. You know, folks need to be licensed. We have all different kinds of rules in every state, uh, which I went into in in great detail in our uh in our presentations. But I think that's something that's critical when new folks come in with, you know, a fantastic idea, helping them understand and navigate the different pieces. So, for example, if you're not gonna have bricks and mortar, we're gonna have to talk about who your payers are. Are you doing a pilot project uh with an MCO or are you gonna try and build Medicare and Medicaid? And if you're gonna try and enroll in Medicare, you're gonna have some issues because there's an enrollment requirement that you're operational, which means you have a physical location. How are we gonna handle that? Um, you know, I've had folks looking at um office sharing uh type situations and kind of defeats the whole purpose. So, can you use someone's home? How is it gonna work? So, kind of getting through those issues first, talking about workforce that might be required by whatever state law ratio there is for supervision is important. Um, those are kind of some key considerations at first, and and helping um our fast-moving business folks to understand you need to set it up right, or you might have to give all the money back. Um or you know, you might get your providers in trouble. I've represented a couple of different providers. One was in the state of Louisiana where, you know, he relied on the company who, you know, engaged me to help the provider. Um, but they were missing a couple of disclosures on their state-specific telehealth um consent form. And we got to go talk to Louisiana State Board of Medical Examiners. And with the companies I've talked to looking to do this with the providers, my experience has been that they are unanimously, you know, behind their providers, don't want anybody getting disciplined, don't want to hang them out there and are protective of the providers, but understanding those risks to the licenses of the physicians and the nurse practitioners, and it's mostly nurse practitioners that I see in these models, um, that's important. Um, there are some you know prescribing limitations. There's one state, it's mine, uh, that has special rules on prescribing obesity drugs. Uh you can't do it via telehealth. And understanding all those little nuances are are critical in looking up, uh setting up those uh virtual practices.
SPEAKER_02:And and that's kind of there were some public health, you know, emergency flexibilities that went through that are at least some of them are going through the end of this year. And then the 2025 physician fee schedule adopted certain flexibilities if you met certain requirements. And now I know the 2026 physician fee schedule is anticipating or at least is proposing to, you know, uh do sort of all for all incident two services, um, more of a broad-based um exception. And so that's something just kind of to keep an eye on for folks that are billing for some of these supervision requirements, Emily. I was tying on to your virtual aspect there, that there were some flexibilities there from a virtual perspective that folks should be aware of um and make sure they look into because you may not have to have that physician for certain things that you're billing directly in the office, they can they can um attend it virtually via some type of audio video communication.
SPEAKER_00:I I um along the lines of innovation, um I I just attended a uh the annual conference for concierge medicine today here in Atlanta. Um and what's what's interesting about the group or just the concept is that I think you're starting to see some APPs even do it in certain states. Um have have has that ever crossed y'all's desk? Uh I mean, I because what what what I'm thinking about is those practices that not necessarily the primary care, but the ones that get more niche, like either your a longevity practice or your uh you know, dealing with biodentical hormones or or something along those lines. Um because as I was sitting there, I was thinking, wow, as a as an APP, you know, this could be another means of of of um developing a practice, developing a following with patients, and and um potentially you know aligning you know a work-life balance or that which providers typically love to do, which is spend time with patients versus spend time with all the administrative stuff. I'm just curious if that's ever hit y'all's desk by any chance.
SPEAKER_02:It yeah, we're seeing a lot more of that, especially in the um, I don't know what you would call it, the cosmetic realm of the case. Where you know aesthetics, yeah, the aesthetics, you're seeing a lot more of that. Um, and and generally when I hear concierge medicine, I I think cash only, um, not participating in Medicare, Medicaid. And so um I yeah, I think you're seeing a lot more of that. And I think they're lucrative practices. You just have to make sure, you know, again, you're you're following all your compliance requirements that you need to meet under the state law where you're providing that service. And if you, you know, if you got to double check and make sure you're not enrolled, you know, as participating in Medicare and things like that, because I have had some situations where the, you know, physicians they're providing hospital services, right? And they've reassigned their benefits to bill and collect to the hospital for purposes of Medicare, but they're over here trying to set up a practice that doesn't accept Medicare and it doesn't necessarily jive.
unknown:Yeah.
SPEAKER_04:Well, and anecdotally, you know, as we're talking about kind of things evolving and having more of a role for the APPs, um, you know, one of the things we were talking about, you know, around the office recently is how long it takes to get in with people. Joe, you were very generous at the beginning of the presentation saying, oh, it takes three weeks.
SPEAKER_00:Yeah.
SPEAKER_04:You know, in my community, it takes nine months to get in with a new TPP as a new patient. And, you know, some of the um my colleagues in the office were talking about it takes six weeks to get in for a visit if you're sick, right? So, and even with little children. So, what I'm seeing, even you know, among my colleagues, is a willingness by, I mean, like young parents to pay for concierge medicine so that you don't have to wait six weeks to get your child seen for a cold. Um, I think that's a tremendous opportunity. Um, again, with you know, the comfort level that we have with APPs these days. And, you know, it is an alternative to urgent care, right? I mean, yes, you can take your child with the cold to the urgent care, or you could sign up for concierge medicine and see the provider that you're familiar with. And the provider has more flexibility and can kind of limit their patient population. Um, it it seems like, you know, maybe even a throwback kind of way to practice, which I think is a little old-fashioned and lovely, where you really just get to focus on your patients and be there for them.
SPEAKER_00:Well, it it it's interesting because this is what my topic was when I was talking, is that um, you know, it's membership based fees have can really range, you know, every anywhere from this executive health um where it could be 10 plus thousand a year to sign up, to a plan that might be in the twelve hundred dollar a month uh Amount per year to sign up. But then what do you get from it? You get direct access to your care provider by text or phone the same day, sometimes same day appointments, sometimes next day. I mean, that's a far cry than nine months. And then whenever you actually are are um are seen by the by the or seeing your provider, the time may be 30, 45 minutes an hour spent. And now you're thinking, wow, this is really more of a relational um type of uh transaction than just purely transactional. Um and and and you when you when you think about it from the provider standpoint, um, you know, and we think in terms of compensation per work RVU, I mean, it is through the roof, not even comparable. Like a primary care visit is somewhere in the$40 to$50 a work RVU to the and in terms of compensation, but when you think about it from a membership fees um to the number of visits, you're looking at 200 plus. So it just, I think the way I like to think of it is it realigns where the value is coming from. It's not about, you know, when I first started, it was, hey Joe, take this two-patient a day clinic and grow it to 40. And if you can stomach 50, go for it, uh, which was is crazy. We did grow it, but that's crazy. To, hey, Joe, take these panel of patients and do the very best you can for those patients and keep them as healthy as possible and as happy as possible, such that the membership rates that they pay make sense for them. And it's just a completely different, you know, frame of thinking. But anyhow, it it made me think. Like I said, I gave the talk on Saturday and I was sitting there thinking, wow, what what what a throwback to sitting in somebody's room and being able to actually sit. I'll I'll leave you with this one just and we can switch gears however y'all want to do it. But uh, when I interviewed at one job, I went from you know the back office, the nursing station, all that stuff, and I went to somebody, oh, here's our typical exam room. And when they opened the door, I said, Well, wait, where's the stool? I was you know, just happy go-lucky, lit learn learn learning everybody, everything around. And how where's the stool? And they said, Oh, we don't have stools, we don't want you sitting down. Okay. This isn't gonna work. Um, but uh, but so so the antithesis of you know, uh that type of concierge practice.
SPEAKER_02:It'd be interesting, Joe, to see patient satisfaction levels on the model you're talking about versus you know the model that we typically see. I bet it's probably skyrocketed or patient satisfaction significant in that concierge model.
SPEAKER_00:Absolutely. I'll tell you right now, just just um, and I was generous with that three weeks. I I don't know what I was talking about, Emily. But but um I I, you know, I as you guys know, I was training for the Iron Man event, uh, which I was super excited. That's probably the only thing I wanted to talk about, which is why I'm finding a way to talk about it here in the podcast. Go for it.
SPEAKER_03:You deserve it.
SPEAKER_00:But but I had an abnormal lab because and and that abnormal lab was on my kidneys. And if you run an endurance event, you can stress your kidneys further. And so that panicked my wife, and that got me going. And it took me an arm and a leg and a couple of doctor friends to get me into a primary care. And at that time, I had already ordered tests, and I'd already, as an NPE and as the with our ability to order tests for ourselves, I did it. And I sat in that first room and I said, here's what I want to talk about. I want to talk about can I do the race or not? It's a nine-month commitment, and I was already five months into it. And I don't think he looked up from his computer but twice, and that was just to say hi, and then the next one was to say, let me reorder your labs. And I'm like, wait a second, we just ordered labs. And there was, I left that appointment after a drive to the to the practice, sitting in the exam in the waiting room, sitting in the exam room, and then leaving out with an order for another lab with like no answers, and completely felt like, okay, this was useless. I did call a friend who I worked with who is in concierge medicine. She immediately took my call. We we we talked through it, and all is good. But um, I think, judging by your conversation, you mentioned Emily, that's exactly what's happening. And as as if providers are willing to do it, that price point for the membership is slightly lower. I think it's definitely gonna resonate with people. Um and I and I and again, I think that's an area that APPs could do. Thinking about you know, pediatrics, and uh it's just one of my loves. Um, you know, you you there's so much education that being given that parents they leave out of an office in 10 minutes with an ear infection of their first child who's two, screaming with fever of 104. I mean, they're still panicked uh about what to do at two in the morning, you know, and there's a lot of education you can do. But anyhow, interesting.
SPEAKER_04:Oh, it's great points. And I think, you know, it kind of ties back into what we were talking about about why APPs are, you know, we're seeing uh such growth in this area because it helps with access and you know helps give patients more attention and time. And I've got to believe that's more gratifying for the provider. Another space where I see, you know, a real need for um more providers is in psychiatry. I mean, the the wait is again, you know, maybe longer than nine months to see a psychiatrist. And those can be, you know, that can be extended using APPs to assist the psychiatrists. Um I know there are some special billing rules when we do behavioral health. Um, but again, I think as those things get figured out, we have the opportunity to really improve health care um for everybody, make it more gratifying for the provider, make it you know, better, have more access for patients. And I think APPs are a tremendous component of that.
SPEAKER_00:I I I agree. Uh that um I worked with a OB and he had three, four, I'm sorry, APPs. And and what he loved about it was that he was able to gain an extra day in the OR. Um, and he ended up seeing most of the complex cases that we had already seen early on. And so it just it and and us as APPs, we love the time with the patients and we love giving them guidance and we love that aspect. I mean, I think if we if we um play to our strengths, um, I think everybody becomes happier. I mean, what the statistic that um we said at one of our uh talks was that um uh burnout is uh uh uh or or feeling some sort of burnout is uh over 50% um when in the physician population. So certainly I think utilizing APPs in in a better, more efficient manner to their license, up to their license, will certainly I think help physicians um practice um medicine that they want to practice.
SPEAKER_02:And there were in the webinar we talked about some behavioral health flexibilities, as Emily touched on that for the incident two billing requirements are a little bit more flexible to make sure that there's get that important access that people are getting uh the needed mental health services that they need access to. And and the APPs and the use of them is gonna help uh promote that.
SPEAKER_00:Absolutely. And a person who is suffering from anything, whether it be mental or physical, um, caught earlier, addressed earlier, it's less expensive for the general population and better for that individual. I mean, it's just there's um a lot of pluses to go around.
SPEAKER_02:So agreed, agreed. Well, is there anything else, Joe, that we've that we failed to highlight that we're I don't think so.
SPEAKER_00:I got my Iron Man in, so I'm good. Um I'm kidding. I'm sorry, I'm hooked. I I I I want y'all to do it with me. Uh but uh no.
SPEAKER_04:I'm training for a half marathon, and that's how much I can go.
SPEAKER_00:Put on a whisk.
SPEAKER_04:So access to a good orthopedist or an orthopedist PA is also important.
SPEAKER_00:There you go, there you go. No, I I I I think we did great. I I I love talking with you guys, and it's been super that AHLA has given us the platform to uh again take our show on the road. And um uh certainly I would reach out to any of us, um, especially if you have any of the legal questions, reach out to my colleagues, Elena or Emily. Um, and um thank you for joining us.
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