Hand in Hand Family Practice LLC, otherwise known as HIH, will be a primary care clinic located in south central Alaska.  It will be managed and operated by Carolyn Wisco, FNP, founder and owner. HIH will focus on diagnosing and treating patients of all ages with acute and chronic illness and providing excellence in care to sustain a profitable practice. 
Mission Statement
To develop partnerships with people in our community, providing education and exceptional care across the lifespan, so they can lead longer, healthier, and happier lives.
Our Core Values
HIH operates with Integrity, Excellence, Respect, Transparency, and Compassion.
Philosophy of Care
Hand in Hand Family Practice, LLC, will operate on the basic founding principle of a “partnership of care”.  Each of its patients and families it serves will be embraced by a friendly, passionate team of healthcare staff. HIH’s primary focus is to build long term patient care relationships, where patient and provider work together to manage the overall health of the people it serves. HIH patients will receive excellent health care services, easy provider access, provider trust, and confidence in their care continuum.
Wasilla Market Analysis
The HIH medical practice will be in the city of Wasilla, Alaska, which is the 6th largest city in the state of Alaska, located in the Matanuska-Susitna Borough. The Wasilla community is currently estimated to have a population of 10,000 people, which has doubled in size since the last census count from 2010. The city is located 43 miles north of Anchorage Alaska. Until 2002, the city of Wasilla was the starting point for the famous Iditarod Trail Sled Dog Race (“Alaska Population Estimates,” n.d.).

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Regarding business climate, there have been many industry changes, increased tourism, new and expanding oil-based companies, and a growing real estate market attracting many people to the city of Wasilla from Anchorage and neighboring communities. The median home price is estimated to be $245,000.00, with an annual increase value of 4.5% percent over the past year (“Captcha,” n.d.). Median Household Income is currently at $62,000.00/year (“Alaska Population Estimates,” n.d.). These metrics indicate a strong working residential community and positive business climate, which means many of the city’s residents likely have medical insurance through their employer. Which, in turn, makes Wasilla an excellent place for a new medical practice.
Additionally, market analysis information reviewed in the Alaska 2015-2016 Primary Care Needs Assessment indicates an exceptional demand for Family Practice providers, with an estimated 49% demand increase for Family Medical Providers until 2030 in the state of Alaska (“Alaska Department of Health and Social Services,” n.d). The Matanuska-Susitna Borough was also ranked 6th for Health Professional Shortage Areas and Medically Underserved Areas (“Alaska Primary Care Programs,” n.d.).  Furthermore, primary care clinics are under staffed, especially in rural locations (“Alaska Department of Health and Social Services,” n.d).  Based on Wasilla’s market analysis, population expansion, business economy, income per household, and Alaska’s primary care providers needed across the state, Wasilla makes for an optimal city for HIH to begin business.
Patient Population Statistics and Services Provided
Wasilla is located within the Matanuska-Susitna Borough, which is estimated at a population of 106,000. 30% of the borough’s population are under the age of 18, 8% are between the ages of 18-24, 31% are between 24-44 years, 24% are between 45-64 years, and the remaining 7% are age older than 64 years.  The population makeup is predominantly Caucasian, followed by Alaskan natives and American Indians, with smaller Hispanic, African American, Asian, and Native Hawaiian or Pacific Islander populations (“Alaska Population Estimates,” n.d.). The HIH market will be largely be based on the patient population of Wasilla but will utilize telecare to serve those within 20 miles of the city, including the cities of Palmer and Houston.
HIH will provide health care services to all people needing medical services in the city of Wasilla, Alaska, and its neighboring communities in the Matanuska-Susitna Borough. HIH will care for patients with both acute and chronic illness of all ages, but most visits will include education and management of hyperlipidemia, obesity, hypertension, diabetes, heart disease, and asthma, based on the most common medical conditions observed in the Matanuska-Susitna Borough Primary Healthcare Needs Assessment (“Alaska Department of Health and Social Services,” n.d). 
SWOT/Industry Analysis
Strengths:

Services provided: HIH will provide patient access to a wide variety of medical services that will accommodate the acute and chronic needs of its patient population. HIH will also offer telemedicine and will be registered with the State of Alaska’s Business Registry (“Alaska’s Telemedicine Business Registry: What You Need to Know | Health Care Law Today,” 2017). 
Electronic Health Record (EHR): EHR provides for technological innovation, patient care and practice management systems, electronic data interchange (EDI) with government and private insurers, patient portal access for provider/patient communication, online billing statements and payment collection, and remote access for HIH medical staff (“Software Platform Built for Your Independent Practice | Kareo, n.d).
Business Location: HIH is located centrally in the city of Wasilla, allowing easy patient access in both city and rural patient populations. The patients in this area often will not have to travel more than 20 miles to see their provider. 
Extended Hours of Operation: HIH will be open Monday through Friday 8 AM-7PM and will also be open half days on Saturdays to provide care for patients when most other primary care clinics are closed.
Staff: HIH will have certified registered health information technician (RHIT) for optimal coding documentation and charges for provider and services. 
Support Network: HIH will have National Nurse Practitioner Entrepreneur Network (NNPEN) membership that will help connect the provider and clinic with essential start up and community resources and offer innovative ways to build, protect, and sustain a thriving nurse practitioner owned practice (“National Nurse Practitioner Entrepreneur Network | We connect nurse practitioner entrepreneurs with each other and with start-up resources,” n.d.).  Cost of this membership is included in HIH’s budget, located in Appendix B.
Competitive Prices: HIH will offer competitive pricing of services and will not over charge for any services provided. 

Weaknesses:

Limited ancillary services: The clinic will not have its own lab or radiology departments, so patients will need to go to nearby lab and radiology facilities as indicated.  While HIH will offer some urgent care services, it will not off the array of services offered by most urgent care clinics. Furthermore, all lab specimens collected in clinic will need to be sent to lab by provider or courier service, depending on time and resources.
Limited Staff: Staff only consists of one provider and RHIT staff, so this may prove to be less efficient in cases of daily high-volume patient encounters. 
New Healthcare provider to the Wasilla community: HIH will have to gain a client base, and it may take months or longer to become a successful, sustainable business.

Opportunities:

Primary Care Provider Demand: HIH can help satisfy the demand for providers in this rural community. In general, the opportunity for growth of our practice in this community has great potential, limited number of mid-level providers, strong economy, and trends in population growth (“Mat-Su Health Services, Inc,” n.d.).
Expansion of Business:  HIH may wish to expand our services in the next several years as revenue grows. More staff may be added as well to enhance clinic efficiency and patient satisfaction. Other HIH clinics may expand business in surrounding cities and counties.

Threats:

Healthcare Reform: Future healthcare reimbursement reform could result in reduce payment rates.
Competing Clinics: Expansion of healthcare organizations in the community may pose threat to the business of HIH with retaining its clients. Other organizations may provide more services or have more staff to accommodate increased patient visits than HIH. There is one large health care provider network in the local area, Mat-Su Health Services Inc., a Community Health Center (CHC).  In addition, there are other small groups of independent practitioners in the area.

   Risk Management Strategies
In complying with Centers for Medicare and Medicaid Services (CMS), Health and Human Services (HHS), Nation Correct Coding Initiative (NCCI), American Medical Association (AMA) and the HIPAA Privacy and Security laws, HIH will leverage our EHR system to also include a practice management component to help reduce the risk of malpractice and negligence claims. Our EHR will improve registration, scheduling, practitioner documentation, coding, EDI claims, reimbursement, statements and collections (“Software Platform Built for Your Independent Practice | Kareo, n.d). Our practice will also comply with all state and federal laws.  Up to 40% of malpractice suits are lost because of an inadequate or incomplete patient record (Roberts, 2007).  Therefore, the provider will diligently chart thorough accounts of each patient interaction within the EHR system, documenting the most relevant and important aspects of medical care and services rendered to prevent lawsuits.  Cost estimate of purchasing EHR is referenced in HIH’s budget as well (“Software Platform Built for Your Independent Practice | Kareo, n.d).  Provider will also utilize effective communication with patients, including reflective listening and conveying empathy and compassion to all patients, which will help build trusting relationships and prevent and adverse patient outcomes (Roberts, 2007). 
Superbill and Coding Ethics
HIH has created a super bill for patient billing of services which will be used to obtain reimbursement for services rendered from payers.  The Superbill for HIH was adapted from another family practice super bill and can be accessed in Appendix A (“Coding and Documentation—FMP Toolbox,” 2018).  It contains all services and appropriate codes of each service provided by HIH.  Even though HIH does not have lab or imaging services and will not charge patient’s for lab or imaging ordered, the superbill includes all lab and radiology services, so patients can bring their lab or imaging orders to nearby affiliated facilities to process these orders. HIH will credential with all major private payors within the Wasilla area, and will partner with Physician Practice Specialists (PPS), a company with the lowest rates for credentialing in the United States, to accomplish this task (“Physician Practice Specialists-Practice Start Up & Credentialing Services,” n.d.).  The cost for partnering with PPS is also included in our budget.  HIH will not turn away patients who have limited or reduced income to pay for medical services. The practice will use a sliding fee schedule for patients that meet the requirements. Our primary services for patients will be for new and established office visits. In addition, HIH will also have many visits pertaining to preventative care, diabetic and other chronic disease counseling, acute care services, and pediatric and adult immunizations. Our practice will also register with the State of Alaska to provide telemedicine (“Alaska’s Telemedicine Business Registry: What You Need to Know | Health Care Law Today,” 2017).  This cost is also referenced in HIH’s budget.
For each bill submitted for payment, the RHIT employee and provider will work together to ensure that documentation and coding meet requirements to avoid fraud and abuse, or false claims (“8 Medical Coding Mistakes That Could Cost You,” 2018).  We will have processes in place for conducting monthly internal audits looking for reimbursement denials, and improve timely filing processes, if needed (“Consequences of Coding Errors | MEREM Health,” 2018).   Ongoing education and training will occur to keep the RHIT employee and provider current with regulation changes. This cost of continued education is also referenced in HIH’s budget.
    Budget Analysis
All foreseeable budget costs to operate the business can be accessed in Appendix B.  HIH will commence with two employees, the provider and the RHIT employee.  Both provider and RHIT employee will receive a salary and benefits, as referenced in the budget (“Salary: MEDICAL BILLING in Anchorage, AK,” n.d.).  The RHIT staff will also serve as receptionist for the first year until enough revenue is made to hire more staff to better accommodate this role.  The cost to practice as FNP in Alaska, which includes the licensing exam fee and the application fees for prescriptive rights and prescribing controlled substances, was estimated at $625, and this value is referenced in the budget (“Alaska Nursing License,” n.d.).  HIH provider will also purchase malpractice tail coverage insurance from the Nurses Service Organization, as it allows an insured provider the option to extend coverage after cancellation or termination of a claims-made policy (“Malpractice Insurance Nursing Professionals,” n.d.).  Providers leaving one state to join a private practice in another state should obtain tail coverage, as standard malpractice insurance typically will not cover prior acts from another state (“Malpractice Insurance: What You Need to Know,” 2007).  
The business will be leased from a rental office found on Craig’s List, furnished with couches and chairs in the waiting room, and includes a breakroom and 3 exam rooms and tables (“WASILLA MEDICAL CONDO FOR LEASE,” 2018).  HIH will pay for utilities including gas, electric, and internet access and phone (“AT&T Small Business | Bundles for Voice, Internet, TV & Tech Support,” n.d.; ENSTAR Natural Gas | All our energy goes into our customers,” n.d.; “Member Services-Matanuska Electric Association, Inc,” n.d.).  HIH will also anticipate other office supply costs, such as computers, fax/scanner/printer, paper, etc., and these costs are included in the monthly budget.  HIH will also purchase an EKG machine with spirometry and pay for it in monthly installments (“EKG Machine Spirometer Combination Machines: Medical Device Deport, Inc,” n.d.).  It is suggested that the average established primary care office medical supplies can add up to $7,000 or more (Culler, et al., 2013).  However, since HIH is a new business with only one provider, HIH will only anticipate spending approximately $5,000 a month on medical supplies and medications.  HIH will also allocate $500 per month for other anticipated medical equipment costs. 
HIH will allocate a large sum of its costs to marketing, as most companies making less than 5 million dollars annually spend approximately 7-8% of their annual projected income on marketing, including website, brand name costs, social media management packages (“How to Set a Marketing Budget That Fits Your Business Goals and Provides a High Return on Investment | The US Small Business Administration | SBA.gov,” 2012).  Marketing will be especially important to HIH as it is a new business and needs a new client base.  The marketing cost was determined based on HIH’s projected revenue.  HIH will also invest in a lawyer to develop the LLC for the business and finance other essential legalities required for starting a new business.  HIH will also purchase liability insurance to protect the business from any unforeseen adverse events that may occur on its premise (“Medical Liability Insurance | Lockton Health,” n.d.).  HIH will also hire an accountant to handle payroll needs and business taxes, etc. (“Anchorage, AK-May 2017 OES Metropolitan and Nonmetropolitan Area Occupational Employment and Wage Estimates,” 08).  Finally, HIH will set aside $200 per month for other unforeseen miscellaneous costs.  
HIH has projected a tentative monthly revenue for providing our services.  Research has shown that office visits in Alaska are on average 29% higher than that of other states.  Charges of services were approximated by multiplying Medicare and Medicaid costs by 0.29, to adjust for the 29% cost increase (“Medicare,” n.d.).  HIH will use this formula to estimate approximate charges for services.  Estimated charges for the most common services or codes are listed in Appendix C.  It is anticipated most revenue will come from preventive services, including wellness visits, vision and hearing screening, sports and DOT physicals; chronic care management; behavioral health visits; and injections, immunizations, and acute care visits.  Types of services rendered daily may vary, so cost of an average visit was estimated to determine number of patients needed to be seen daily to break even.  The average primary care office visit in Alaska is $200 (“Health care costs are biting Alaskans, business harder,” 2012).  HIH plans to be open for business 24 days during the month, which includes the sum all half days on Saturdays.  The average monthly cost to operate the business is approximately $34,905.  However, to account for difference between HIH’s billed fees and reduced reimbursement from payers, such as Medicare and Medicaid for family nurse practitioners and other commercial payers, patients with bad credit, and varying cost between new and established patients, an additional $10,000 will be added to our estimated gross monthly cost to operate the business.  Therefore, it is important that HIH generates gross revenue of no less than $44,905 per month to be within the range of breaking even.  To determine the number of patients required to be seen each day, $44,905 (projected revenue) was divided by the total number of days HIH will be open a month (24 days).  Then this value was divided by 200 (estimated average cost of one patient visit) to determine the projected number of patients needed to be seen per day at HIH.  Based on this equation, the total projected number of patients per day needs to be at least 9.  However, HIH will strive to see at least 15 patients per day (less on the half days) to surpass the break-even point and bring in added revenue to utilize for other unforeseen costs and save for business expansion costs.  It is estimated HIH can make approximately $72,000 gross monthly income from services if 15 patients are seen per day.  This number is tentative as visit prices and number of patients seen daily will fluctuate.
 
Appendix A
 
 

Appendix B
 
 
Appendix C
 

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