Reducing Administrative Burden

Veronica Max had seen enough. In 2013, Texas was failing to close a primary care gap that jeopardized the health of good people, especially those in rural communities, where they could drive 100 miles without passing a doctor. Max’s state forecast a shortage of 3,375 primary care physicians in the coming decades, reflecting a trend sweeping the nation. The implications — like a lack of preventive medicine and deaths that might have been avoided with an early diagnosis — haunted Max.

“People are dying right now because they don’t have access to primary care,” she recalls thinking. “We need to change that.”

Max was a nurse practitioner who spent years working for a large health system and then a small primary care practice that specialized in traveling to patients’ homes. She understood the need to care for patients who lived off the beaten path, the forgotten. If Texas was facing a primary care physician shortage, Max knew in her heart and from care quality data that advanced practice nurses could step in.

The challenge also presented a business opportunity. If she started a home care practice, she could find a nearly limitless patient base. Plus, primary care visits with nurse practitioners typically cost less than those with physicians, which boded well for reducing the country’s soaring healthcare tab. All of her senses were screaming to start her own practice.

But thanks to cumbersome government regulations and unfavorable insurance reimbursement policies, nurse practitioners have never had a simple path to entrepreneurship in the U.S. Consequently, as little as 0.5 percent of U.S. nurses have started their own practices. To open a primary care practice, Max would need to venture where few had even tried.
“It was super hard,” she says. “I felt like I was alone, like I had to find my way around this dark room without any help.”

Healthy Roots

In middle school, when most kids were busy watching TV or dodging homework, Max read every nutrition book she could find. Something about food and its effects on physical performance fascinated her. In college, she researched her way to a more primal diet — meat, veggies, and fruit — with no processed foods and few sugars and carbs. As a Division I basketball player, she noticed that a better diet translated to a better game on the court.

It was an epiphany. Max felt like she had gained control over her health, and she wanted to share that sensation.

“I thought I wanted to be a doctor,” she recalls. “But during the summer before my senior year, I got an externship at Vanderbilt, and I saw a pediatrician there who was working 24-hour shifts while six or seven months pregnant. And I asked myself if that was really what I wanted to do. I wanted a family, and I didn’t think being a doctor offered the simple lifestyle I wanted.”

When she graduated college, she felt lost. Basketball was everything to her. Now, her playing days were over, and with them went her direction.
Max returned home to contemplate her future. She started working for her dad, who owned a real estate firm. Since she was little, she watched him and her mom, a nurse entrepreneur, do the things that make businesses work: deal making, management, and critical thinking. Spending time in her father’s office inspired Max. One day, she thought, she might run a business, but it certainly wouldn’t be in real estate.

Even after the final buzzer ended her basketball career, Max remained fixated on nutrition and performance optimization. The realization hit her hard: Healthcare could turn her passion into a career.

“I wanted to have more autonomy than a nurse, so I was either going to be a physician assistant or a nurse practitioner,” she recalls. “I started doing research and learned that nurse practitioners go through the nursing model, which is a more holistic, whole-body approach. I was called to it.”

When Healthcare Disappoints 

Max thought she had mapped out the path to happiness: Get a second bachelor’s degree, work her way through nurse practitioner school, and then raise a family and provide preventive care to patients. 

When she landed her first nursing job, however, things changed. She spent her days studying to become a nurse practitioner and nights working in a large Texas health system. She quickly found that big healthcare wasn’t personal in the way she had hoped.

“In a large system, they call it human resources. I hate that name — the idea that we talk about humans as resources,” she says.

The health system forced its employees to document everything to support billing and risk mitigation. Each 12-hour shift was rife with precautions and bureaucratic procedures that tore Max from her patients. Hospital policies led to understaffing that placed patients at risk. Reality frustrated Max more each day. If patients weren’t the priority, then why had she entered healthcare?

“I worked trauma, neurology, and oncology, and it was not unusual for us to have six patients. Some of them were critically ill, so I might have been giving a blood transfusion or chemotherapy while another patient was coming back from surgery and needed to be closely monitored,” she recalls. “It was just very unsafe and highly stressful.”

After two years, Max left to join a fledgling primary care group as a nurse practitioner. The founder, a physician, saw an untapped business opportunity: mobile IV hydration, much like the services found across big cities today. Athletes looking for a quick boost loved the concept, and the practice took off. Max, meanwhile, was stunned by how smoothly a good idea grew into a strong business.

“Because it was a small practice, I saw the back end and learned what it took to run a healthcare practice,” she says. “I honed my skills as a nurse practitioner, and I got comfortable with the idea of starting my own practice.”

The Move to Independent Primary Care

Although Max enjoyed working for the clinic and several side gigs, she knew Texas didn’t have enough primary care physicians, healthcare remained too expensive, and most clinicians were cogs in a much larger machine. She was thrilled by the potential of telehealth and home care, of nurse practitioners and herself, to solve those problems. She ached to go out on her own, but she had no idea where to begin.

“My dad had died at that point, so he wasn’t around,” she says. “I had these ideas, but I just needed someone to believe in me. And my husband believed in me.”

For years, Max had mulled the idea of starting her own business and taking control of her life. Now, with the support of her husband and careful planning, she was finally ready to face the uncertainty. 
With just $2,000 in startup capital, Max opened her first primary care practice.

“It was super scary,” she says. “I had three jobs plus the business I started because I didn’t feel comfortable. I was always very afraid of having debt.”
The practice was moving forward gently when Max landed a contract for substance abuse treatment. Her business immediately blossomed. One contract led to more, and she began hiring employees with psychiatric backgrounds and using telemedicine to reach rural populations.

“It was running great, we were providing excellent care, and the best part was that I didn’t have to worry about it,” she says.
All of the grueling shifts, calculated risks, and soul-searching paid off. She made it.

As time went on, however, Max began to long for change. She wanted to shift from substance abuse treatment to her first loves, preventive medicine and health optimization. She thought about how that path might offer more flexibility, more joy. Eventually, she made the tough decision to shut down her clinic and launch a new one called UltraPersonal Healthcare.

This time around, the process required less emotional risk. Max knew she had what it took, and she teamed up with another nurse practitioner. They chose to operate under a direct primary care model. No longer were revenues tied to patients falling ill or insurance reimbursements. Max could earn market rates for spending more time with patients.

“I like to spend time with my patients, to educate them, and direct primary care enables me to do that,” she says. “I can’t imagine going back to the way I provided healthcare before.”

After less than a year in business, UltraPersonal Healthcare had signed on 300 patients.

Nurse Entrepreneurs Can Shape Healthcare

Healthcare remains broken in many ways, but Max believes more than ever that nurses can fix it, if only they can overcome the challenges facing startup practices. That’s why she established the American Academy of Nurse Entrepreneurs, a group that helps advanced practice nurses go into business. She has mentored a psychiatric nurse practitioner who launched a company that employs 10 clinicians and treats pediatric and Medicare patients. Another one of Max’s protégés recently opened a practice to promising early results.

Here’s some of the advice she gives her colleagues:

• Get support from other nurses. When Max set out on her own, she had few resources and mentors to consult. By 2016, more than 150 nurse-led practices had cropped up in the U.S. There’s no need to reinvent a successful model when nurse entrepreneurs can reach out to their community, including Max’s organization, for help.
• Take care of yourself. It’s tempting to work long hours at the office and at home, but it’s imperative that nurse entrepreneurs keep themselves healthy and happy. Max uses CrossFit to check those boxes. She also secured Elation Health as her electronic health record provider to ease clinical documentation, which makes her job smoother than ever before.
• Don’t get intimidated. State regulations and insurers pose roadblocks for nurse entrepreneurs, but they’re surmountable. Direct primary care is one way to get paid your worth. And don’t forget, Max adds, that advanced practice nurses are proven to provide primary care whose quality is equal to, if not better than, physicians.

As the U.S. physician shortage intensifies in the years to come, the healthcare system will need more nurse practitioners to fill the void. Challenges, from restrictive state regulations to the fear of failure, will continue to keep some people from heeding the call. But if they learn anything from Max, it’s that nurse practitioners can and must prop up independent primary care — because few others will.

“We’ve got a problem with healthcare in this country right now. It’s too expensive and we also don’t have enough providers,” Max says. “The nursing profession offers the solution.”