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    Midlevel management

    A rural Indiana family physician manages a crew of nurse practitioners, works a short day, and still makes a profit with most of his patients on Medicaid and Medicare

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    "I know if this appears in print, I'm going to be a pariah and in the crosshairs of a lot of docs," says family physician Bruce Ippel, MD, without a hint of sarcasm in his voice.


    Bruce Ippel, MD, and family nurse practitioners Jennifer Huisman, Lisa Swingley, and Vicky Owens maintain a supportive practice environment where the midlevels feel free to work with minimal supervision and are not intimidated to ask questions.
    Ippel is sitting in the tiny lunch room of his practice, Thoroughcare PC, located in a brown and tan, solar-heated building, tucked between corn and soybean farms outside of New Castle, Indiana, a town of 18,000 residents, an hour east of Indianapolis. It's just past 10:30 a.m. on a Tuesday, and Ippel's already done seeing patients for the day. Yet outside, in the practice's 6 exam rooms, Ippel's 3 family nurse practitioners (FNPs) are seeing patients and will do so until the practice closes for the day.

    The 60-year-old Ippel runs a federally designated rural health clinic (RHC). In a typical week, he sees about 40 office patients, but his FNPs—Vicky Owens, Jennifer Huisman, and Lisa Swingley—each can see approximately 100.


    Family nurse practitioner Vicky Owens enjoys managing her own caseload of patients who come to see her regularly.
    "Are they as competent as your average primary care physician, seeing primary care patients? Here's where there's going to be trouble: They're better..." he asserts, pausing to the let the words sink in.

    How so?


    Thoroughcare's family nurse practitioners, each of whom sees 100 patients a week, say that Ippel is always available to them, whether he is in the office or not.
    "Because of the way it's structured here, they have the time," he says. "I don't tell them they have to see 'X' number of patients per hour."

    Half of Thoroughcare's patients are insured by Medicaid, and another quarter have Medicare. The practice's gross revenue last year was $774,000. Ippel earned $140,000 and paid each FNP $80,000 to $90,000 while picking up their medical liability premiums.


    Ippel says open communication and patient feedback keep him aware of his midlevels' performance.
    Due to Thoroughcare's RHC status, the practice receives a $77 fee per medically necessary encounter with each Medicaid patient, which can be double or triple non-RHC Medicaid rates. But Ippel attributes more than just the enhanced reimbursement to his success. Although he pays FNPs less than he would a physician employee, Ippel says his midlevels attract and retain patients better than doctors due to the practice style at Thoroughcare and that he is confident about their patient care quality.

    "Patients will say, 'Oh, I love her. She's really helped me here and there,' " Ippel says. "That thrills my soul because that's what we want to do. These are patients who oftentimes don't get the time of day from other healthcare practices."

    Ippel says that his transition from being a solo physician with minimal help to managing a team of nurse practitioners has fulfilled his vision of creating a rural family practice focused on preventive care.

    "Primary care is not just about treating your poison ivy or chest cold, but preventing you from having your heart attack," Ippel says. "That's where the big potatoes are."

    HUMBLE BEGINNINGS

    Despite being born, raised, and educated in Chicago, Illinois, Ippel always saw himself as a country primary care doctor, treating all patients from babies to the elderly.

    He sought out a residency program that shared his values and found one at Ball Memorial Hospital in Muncie, Indiana, about 20 miles north of New Castle. After residency, in 1987, Ippel decided to stay in New Castle. There were already several family physicians in the town, so Ippel chose to build his practice outside of the city, where he saw a greater need for the kind of preventive healthcare he practiced.

    "The banker was more than happy to work with me," Ippel says. "I came out of medical school, thanks to my wife, debt free. I had no real debts, and I had an MD degree, which translated into real easy to get a loan."

    Ippel built his office for 2 doctors. When his patient panel was full, Ippel began to search for a physician employee or partner but early on in the process realized he couldn't recruit physicians like the larger multispecialty groups with guaranteed minimum salaries and predictable work schedules.

    "The reality is, if you're going to put in 4 years of medical school, 3 years of residency, you're going to go where the money and call schedule is," Ippel says. "That ain't out here."

    By the late 1990s, more of Ippel's patients had joined PPO health plans with which he wasn't a network physician or listed in the health plan directory. Although he tried to get on as many networks as he could, many health plans either never returned his calls or treated him like "small potatoes," he says.

    "My 20 patients a day dropped to under 20," he says. "When you're in a place like this, overhead is what gets paid. You get paid if there's anything leftover."

    While researching his options, Ippel learned about the RHC designation.

    RHCs were authorized by the federal government in 1977 for the purpose of improving access to care for Medicare and Medicaid beneficiaries. They receive an enhanced reimbursement, which varies by state Medicaid rates and the physician's volume. The physician must be located in a rural area with a ratio of approximately 3,500 residents per primary care physician. Because Ippel already was seeing Medicaid patients, the higher fees seemed like a solution that could help him stay in business.

    "I had the choice of either closing the doors, moving into town and becoming part of a big, multispecialty clinic, or becoming a rural health clinic," Ippel says. "I thought, well, this rural health might work."

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