Lessons on Opening a Practice From a Successful NP Entrepreneur

I'm always inspired by nurse practitioners who take on the challenge of starting their own practices. The task personally sounds quite daunting to me! So, over the next several weeks we're featuring NP entrepreneurs here on the MidlevelU blog. While starting your own practice is hard work, it is a career adventure that can have benefits - a more flexible lifestyle and higher income to name a few. Dual certified Adult and Family Nurse Practitioner Cynthia Malowitz, founder and owner of Bay Area Quick Care, is one of these success stories, thanks to her perseverance and unmatched work ethic. 

This week, I had the pleasure of chatting with Cynthia about her experience opening her own urgent care clinic. She shared some powerful insights for entrepreneurial NPs interested in stepping out on their own. Here's a peek at our conversation.  

Tell me a little bit about your background before you decided to open your own urgent care clinic.

Cynthia had a varied background before jumping into her solo endeavor, but "I was never really an employee", she says. Cynthia worked for six years as an independent contractor in urgent care, internal medicine and family practice settings. She often filled in for physicians when they took vacations or needed an extra set of hands. Working in urgent care was her favorite setting and she decided opening her own clinic would be a good path. As an Adult Nurse Practitioner, this was a long road. First, in 2008, Cynthia had to go back to school to obtain her post-masters Family Nurse Practitioner degree so she could treat children. 

What was the process of opening Bay Area Quick Care Like?

In April 2010, Cynthia realized her dream and opened Bay Area Quick Care in Corpus Christi, TX. And, the clinic was, well, really slow. The clinic was open 12 hours/day, 7 days/week yet only served 28 patients in its first month. In her first year of clinic ownership, Cynthia earned far less than minimum wage, taking home just $15,000 as her salary. But, she persisted! "I had promised myself that if I broke even the first year I would stay open", she recalls. So, with her small profit, Cynthia kept her doors open. 

What did the growth of Bay Area Quick Care look like?

For the first four months the clinic was open, Cynthia was the only employee. She manned the front desk and saw patients. Then, she hired a part-time receptionist to help during the busiest hours of the day. One year after the clinic opened, Cynthia's practice finally maintained high enough volume to support a full-time receptionist. After 18 months, she added a medical assistant to her small team and also expanded from 1,100 square feet and two exam rooms to a 2,800 square foot space.

Cynthia approached her urgent care clinic's growth very conservatively. She avoided debt, and instead worked long hours herself rather than hiring employees before this could be supported by the clinic's revenue. "The chances that a new business will go under are pretty good" Cynthia stresses, "the last thing I wanted was for my business to fail and still owe a lot of money". Cynthia advises others who are opening their own clinics to avoid taking out loans if at all possible. This keeps your financial liability low if things don't work out. 

What has been the most surprising thing about opening your own clinic?

"Many people don't realize that contracting and credentialing are different" Cynthia warns. While getting credentialed with insurance companies as a nurse practitioner is easy, NP clinic owners also need to have contracts with insurance companies to receive reimbursement for services rendered. "I was surprised by how anti-nurse practitioner the insurance companies are" Cynthia says. Medicare and Blue Cross gave Cynthia a contract without much hesitation, but other insurance companies in the area were difficult to work with. They would not offer a contract to a nurse practitioner owned clinic. Finally, Cynthia put her foot down and told these companies that she would send their urgent care patients to the emergency department for care if they would not contract with her. This leverage motivated the remaining companies to work with her. 

Cynthia emphasizes the importance of contracting in the success of a clinic. She advises that nurse practitioners interested in opening their own practices must do their homework. NPs need to know how much they will be paid for the services they provide and understand that their reimbursement rates will be significantly different than those of physicians. To renegotiate these contracts, clinics must see thousands of patients. Reimbursement rates won't improve unless you are successful. 

What has been the best thing about having your own clinic?

Opening a practice is hard work, "you have to be there" Cynthia says. During the first three years Bay Area Quick Care was open, she took only 4 total days off. Now, her hard work is paying off! Cynthia employs nurse practitioners and physician assistants who take primary responsibility for seeing patients at Bay Area Quick Care. This gives Cynthia the flexibility to travel and spend time with her family as well as work on the operational side of the business. She is able to spend part of the year in Arizona and Nicaragua with her husband. "If you would have told me eight years ago that we would be doing as well as we are today, I wouldn't have believed you" she says. "After the third year we were open I was finally able to step away and start working less, we were busier and I was getting better rates from insurance companies" Cynthia recalls. 

What has been the most challenging thing about owning your own practice?

"Dealing with staff!" Cynthia exclaims when I ask her about challenges. A number of small issues constantly arise among staff members that must be addressed. Weekend staff are also part-time employees so the clinic sees a lot of turnover in these positions. 
 
How do you handle the physician collaboration requirement in Texas?
 
The physician collaboration requirement is a difficult one for many nurse practitioner practice owners to navigate. Cynthia, however, has been very fortunate to have a supportive collaborating physician. She pays a monthly fee to this MD. Cynthia and the NPs/PAs she employs all collaborate with this same doctor. Another positive is that Cynthia's practice is in an underserved area. This gives more freedom with state collaboration requirements. Rather than being limited to collaborating with up to seven NPs, collaborating physicians in underserved areas may supervise an unlimited number of nurse practitioners. 
 
What advice do you have for nurse practitioners who want to open their own clinics?
 
"You have to be there!" Cynthia again emphasizes. And, "realize that it might be two years before you get a paycheck" she advises. Cynthia recalls talking with a new NP practice owner who left his clinic on afternoons when it wasn't busy to go golfing. The clinic, needless to say, went out of business within months. Cynthia put in thousands of unpaid and underpaid hours to get to where she is at today. If you want to own a successful practice, you must be willing to do the same. 
 
A second piece of advice she offers is to "understand that insurance companies are very anti-NP". Know which networks you will be a part of and how much you will be paid with each network. Contracting with insurance companies is a crucial piece of success. 
 
A big "Thank You" to Cynthia for sharing her experience with us, the hard work and determination she put into founding her own clinic is inspiring...and an important reality check for aspiring NP practice owners. 
 
 
 
Cynthia Malowitz is the owner and founder of Bay Area Quick Care, Inc.  She has 22 years of experience as a registered nurse and she has been a nurse practitioner (NP) for 13 years. After graduating with a M.S. in Nursing from Vanderbilt University in 2005, she began her career as an Adult and Gerontological NP.  She obtained a post-Master's certification as a Family NP from the University of Texas Health Science Center in Houston in 2008.  Ms. Malowitz is board certified by the AANP as a Family NP and by the ANCC as an Adult NP.  
 
 

Comments

What a great example of hard work and determination!

Kelly Witbeck

So very proud of you Cynthia. You had a goal and you kept at it. You are a breath of fresh to the world of APRN's.

Michael Wiggins...

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