In this episode, find out how to add depth to your team and a better patient experience with Duke PA Lisa P. Shock.
“It’s just invaluable the breadth and depth that the team creates by bringing those interdisciplinary collaborative experiences.” -Lisa P. Shock, DrPH, MHS, PA-C
In today’s episode, Dr. Jen Barna talks with Physician Associate Lisa P. Shock. Lisa received her PA education from Duke University and her Doctorate of Global Public Health from UNC Chapel Hill. In this conversation, Lisa shines a light on the immense benefits of having a practice that includes an interdisciplinary collaborative team. Having physician associates, nurse practitioners and pharmacists on staff, for example, can provide a better patient experience and improve your bottom line as well.Tune in to gain more knowledge about the role a Physician Associate could play in your practice.
Lisa P. Shock, DrPH, MHS, PA-C
Industry Expert
Lisa P. Shock, DrPH, MHS, PA-C is an innovative population health executive with National expertise in Medicare, Medicaid, and Value Based Care. Bringing 15+ years of experience managing clinical services within healthcare environments, she has expertise in all areas of clinical operations, value-based care, technology and telehealth, sales, strategy development and communications. Throughout her professional history, she has had repeated success managing population health initiatives, driving performance, and utilizing strong interpersonal skills to achieve organizational success. Additional areas of expertise include operational management, leadership, research, business solutions, quality improvement, organizational effectiveness, health policy and population health.
Lisa is a subject matter expert in geriatrics, rural communities, and post-acute care with continued clinical practice. Her academic teaching experience includes expertise in Community and Family Health, Geriatrics, and Rural Health. Lisa serves on the North Carolina Institute of Medicine Board of Directors and is also the Co-Chair of the Health Policy Committee for the North Carolina Medical Society, providing leadership in medicine by uniting, serving, and representing physicians and their health care teams to enhance the health of North Carolinians.
Lisa is currently one of the only Physician Associates (PAs) nationwide with active experience in outpatient medicine, inpatient medicine, long term care, Population Health administration, consulting, and academics. She received her PA education from Duke University and her Doctorate of Global Public Health from UNC Chapel Hill.
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Please enjoy the full transcript below
Lisa: It’s just invaluable the breadth and depth that the team creates by bringing those interdisciplinary collaborative experiences.
[DocWorking theme]
Jen: Welcome to DocWorking: The Whole Physician Podcast. I’m Dr. Jen Barna and I’m so excited today to have with me here, my good friend and expert, Lisa Shock, public health expert, and Lisa is currently one of the only physician associates nationwide with active experience in outpatient medicine, inpatient medicine, long-term care, population health administration, consulting, and academics. She received her PA education from Duke University and her Doctorate of Liberal Health from UNC, Chapel Hill. Lisa, thank you so much for joining me today on DocWorking: The Whole Physician Podcast.
Lisa: Thank you so much. I’m so grateful to be here.
Jen: I’m really excited to talk with you. Lisa, can you tell me a little bit about your background and some of the things that have brought you to the place where you are currently?
Lisa: Sure, thank you. My favorite poem, you may or may not know this, is The Road Not Taken by Robert Frost. I definitely think my career path has shown that. I am a Duke PA and really grateful for that and really proud of that, and I’m also a Doctorate in Global Public Health from UNC. I have had a very colorful career doing a lot of different things, and really trying to change healthcare delivery for the better. My passion has been around geriatric in senior care and vulnerable populations, and I still continue to practice in rural North Carolina, and I do both primary care and urgent care on a part time basis.
My systems work has been over the last decade or so, one of my roles was with a global organization. I have done full risk Medicaid models working in Medicare delivery systems. That’s been really, really fun and interesting to really try to influence a patient’s journey through the healthcare system by changing that delivery system and creating interdisciplinary collaborative teams that can help support that patient’s health. In addition, I’ve been very active on the Institute of Medicine board, I’m a co-chair of the policy committee for the North Carolina Medical Society, I enjoy doing that type of work to again try to influence the healthcare atmosphere for the better.
Jen: Lisa, with your experience across all of these areas, you also have a consulting business where you help physicians to place advanced practitioners within their practice. Is that right?
Lisa: Yeah. So, it’s a smaller portion of my time lately, but I definitely have worked with small practices, and hospitals, and physician groups to help show them how PAs, and nurse practitioners, and other interdisciplinary folks can really add to their teams. Not just add from a financial perspective, but really add from a holistic care perspective, and really work collaboratively to improve health outcomes.
Jen: So, tell me a little bit about your experience personally with that in your own practice, when you co-owned a practice with two PAs and one physician, and the depth of the team when you have a multidisciplinary team as well as how you see that improving a practice when you go to work with a practice currently?
Lisa: Sure. So, I entered into that adventure with another PA and a physician colleague, and we essentially bought a practice that two physicians were selling in the rural community that I’d spent many years practicing in. As you might imagine, it had one small rural hospital and it was 50 miles from a bigger hospital, and it was just a good community that needed care. At that time, and this was more than a decade ago now. We were pretty pioneering. There weren’t that many PAs owning practices and the laws in North Carolina allow for that. We did want to do everything very aboveboard. Meaning that, we wanted to make sure that we’re following all the rules and doing everything really appropriately, our physician partner did practice within the practice. We ran the practice but he was definitely involved and saw patients as well because that’s always kind of the defaults, “Oh, my gosh, these folks are out on their own, and they’re doing things independently that could be outside of their scope,” and that was never the case in our group.
We took primary world health care really seriously, and we felt like our presence in the community really enhanced the care, and we created jobs. We had nurses, nursing assistants, and front desk staff, and this is a community that had high unemployment due to the textile industry leaving the community, and a lot of farmers and tobacco workers that were struggling. So, we felt like, we were there to do really good things and through our building of the practice and participating in different state programs, I feel like we definitely did that. I always joke that we were reporting quality measures when it wasn’t cool yet. We participated in a state initiative to report metrics around diabetes and other chronic diseases, and our data informed some of those early works that have now become more mainstream, not just in North Carolina, but nationally.
Jen: I’m absolutely certain that your practice enhanced the care of the community, especially, knowing you. So, tell me how that now informs your ability to help other practices to acquire PAs and other practitioners in order to add depth.
Lisa: So, another thing that we did when we owned the practice was we were a preceptor site, and we were a training ground, not just for physician associates. Now, we changed our name. But also, nurse practitioners, pharmacists and medical students. So, we really had that cross section from a training perspective as well as a practice perspective. And that was especially rich to help contribute to that learning and show learners who are coming up in the system kind of an alternative way to do things if they hadn’t been exposed to the broader team. For me, as a clinician, like I said, I do still practice part time. There’s an old saying about “Driving a car, you have to look through the windshield to see where you’re going instead of looking at your feet.” [laughs] And I think, it’s really easy in a really busy clinical practice environment to be looking at your feet a lot.
That ownership time, and that time running the practice as the president of that corporation and doing all of the financials, and the accounts receivable, and the HR, and the hiring, and all of that work, really for me gave me that depth and breadth of several years of on-the-job training to understand reimbursement differences for PAs or nurse practitioners versus physicians for example. And also, to really understand how payers are reimbursing, and credentialing, and how practices often don’t optimize their operations in a way that can really get paid for work they’re already doing, whether that’s on the quality improvement side or the billing side. I’ve worked in hospital systems that I know didn’t bill for my services, and they easily could have. That was just money kind of left on the table. A lot of times policies, or procedures, or regulations are in place from a more historical perspective, because we’ve always done it that way.
Well, things are always changing. And through my work with the medical society, with the State Academy for physician assistants, with our National Academy, and just doing policy work in general, times are changing, and there are definitely ways in my executive population health roles, I’ve definitely learned about value based contracting, and ways that teams can deliver excellent care, and get paid for reducing total cost of care and improving quality for a population. That’s a team effort and that’s a lot of money. When I was Medical Director in one of the ACOs that I worked in, we saved tens of millions of dollars as a system for the population that we were serving.
Jen: And so to hone down to the individual level, if you’re a small practice owner and you wanted to expand your team, how would you begin to determine what the most important factors are in finding not only new practitioners to add to your team, but also how would you recommend that someone goes about figuring out the right person and the right characteristics to look for in someone to build a practice successfully?
Lisa: Sure. So, I’ll give you a couple of examples. So, some practices– not everybody does primary care, some practices are very specialized. Even practices that do primary care may be in the high Medicaid area for example. So, getting that really good baseline intake is incredibly important to understand who are the people you’re serving, who are your patients, what is the population that tends to frequent your practice, and who are they? Are they typically younger, are they typically older? If it’s a high concentration of Medicaid, it’s probably more moms and babies and more kids. If it’s a more internal medicine, Medicare type of practice, it’s probably more older folks. So, as a practice owner, your pay resources are going to be Medicaid, or Medicare, or other commercial insurance products. Understanding that percentage of the pie and how much you are relying on revenue as a practice from one category or the other definitely can help determine how you can maximize your operations and ultimately your revenue.
So, for example, I had a practice that was very heavily Medicaid and did a lot of work with kids with asthma. In that particular example, getting a nurse clinician that had a lot of asthma experience, and could really help the patients understand an asthma action plan, when to go to the emergency room, how to take their medications, using their spacers, that was incredibly important to that group. So, that ended up being a very high priority hire for that group in order to not just potentially have new codes to bill for asthma education, but also really providing a service to that population, because they had such a significant number of asthma patients, it really made a difference to their overall population health.
Jen: And so, when you start to work with a client, do you typically sit down with them and sort out what their needs are, and then, do you actually help them find those people?
Lisa: Yeah. So, I have done that. It’s interesting in the years past, when I was doing consulting a bit more full time, I thought my business niche was making the recommendations. But people kept saying, “But we want you to find a person [laughs].” So, I ended up for some small hospitals and for some small practices. I had one client who was like, “I want to do PA. That’s what I want.” [laughs] And I said, “Okay.” So, going through and a lot of times people are busy. Clinicians go into medicine for pretty noble reasons. We want to be helpful, we want to heal people, we want to improve health, but at the same time, we do have to keep the lights on, we have to pay the rent, and we have to manage the expenses of running the practice, if you are in a more independent environment.
So, creating opportunities and showing, I like to show through data. So, I like to really look at, what is your payer mix, what type of patients are you serving in your community, and how are your reimbursement rates? Some of the smaller practices don’t have the contract negotiation strength because they are small. That’s how some of the larger independent physician associations form, and that’s how strength in numbers, they can then participate in other contractual arrangements that will potentially improve their reimbursement rates on a per patient basis.
The other thing I would add here is that, there’s a lot of practices who are getting just kind of barraged with all the population health quality metrics and value-based type of efforts. I think they don’t really know how to do that. They’re just reflexively responding. I have one client now who is really committed to not just doing fee for service type of work, but really wants to get more involved in the quality improvement and population health arenas. And that business is all around good coding, quality metrics, measurement and data. So, those are areas where the smaller practices tend to struggle a bit more because they just don’t have the people. They don’t have an actuary, or they don’t have a data analyst, or they don’t have someone sitting in their medical record all day extracting data from charts, creating a registry, so that can become more challenging for them.
Jen: Yeah. What do you recommend for a practice that’s in that situation?
Lisa: There are some really good resources out there. I always say, for a practice big or small, it’s build by it or collaborate on it. Some places like to do their own things, some places have a little bit of extra funding to be able to make that investment in their practice. Maybe a practice is hopeful to get owned or purchased by one of the bigger systems, so they’re going to do some of that pre-work to make themselves a more attractive candidate like staging their home, but there are other programs like the North Carolina Medical Society through the community practitioner program has some practice transformation resources that small rural practices have definitely benefited from over the years.
There are other state-run programs and benefits like through the Office of Rural Health and other agencies that are designed to help the individual practices. The reality though is the number of individual small practices is shrinking rapidly. There’s a lot of consolidation in the market. Most practices more recently have been involved with bigger systems, and then they can draw on those resources from those larger health systems.
Jen: Right. Yeah, that’s certainly a huge trend.
Lisa: Yeah.
Jen: I’m curious to know your experience practicing in North Carolina right now as well. I would love to know what you’re seeing among PAs in terms of dealing with the pandemic and how people are holding up?
Lisa: It’s definitely been challenging. Recently, I was talking with a PA colleague. Even simple things like, can you give the flu shot with a COVID-19 booster? A month ago, that wasn’t cool. That wasn’t recommended. But now it’s okay. I think PAs as well as physicians and everyone who’s on that clinical team, we’re struggling with the movement of the cheese, like wake up every day and check my newsfeed, and I feel like I get data that’s conflicting every day about, how to do one thing or how to do another, who is the booster recommended for, what are the side effects I need to worry about, are there really clotting and cardiac side effects from different things, and what are the symptoms of longer COVID, and how can we address that? And then, obviously, we get sick too.
I’ve seen in my urgent care setting we’ve had colleagues who have just gotten sick. Some really sick, some not so sick, but that affects our workforce, and our ability to deliver the care that we’re assigned to do. So, it’s definitely been an incredibly challenging time. The most interesting trends that I’ve seen, I’m on faculty at Campbell, and I do some guest lectures in the PA program, and I teach in the doctoral program. The new grads are having a longer ramp to getting their employment. That’s been the first time that we’ve seen that. Usually, the job market is really, really rich for PAs as they’re getting out of school. But I think a lot of healthcare organizations are experiencing that pandemic uncertainty where they’re still not recovered from some of the challenges, especially in the specialties of elective surgeries. They’re still not completely out of the backlog yet. Some of those financial balance sheets, “Do we really need another person, can we get by,” I think there’s a little more hesitation on the hiring side. They’re still getting jobs and they’re still getting well-paying jobs. but I think it is just taking a bit longer for the new ones.
Jen: I saw an interesting discussion about this the other day, in a thread of a physician group, and it was talking about this question in the healthcare arena about whether we’re actually seeing because you see these reports where a nurse, for example, might say, “Well, I’ve seen a lot of people with clotting due to the vaccine.” The person was asking, “Has anyone seen that in the group?” No one had seen it from the vaccine. They had only seen it from COVID. So, I’m just curious from the vaccine perspective in terms of the work on the frontlines. If you’ve seen any issues with the vaccine itself or whether you’re seeing issues related to people who are unvaccinated and becoming seriously ill.
Lisa: Yeah. I would say more the unvaccinated becoming seriously ill. In my rural community, where I have practiced for years, and the place that has my heart in North Carolina, there was a pretty high concentration of unvaccinated folks, and I’ve seen and heard about more deaths in that community as a result. And those folks, when they did get the Delta variant, were getting much sicker, and the ones that have passed are by and large, the ones who are unvaccinated. It’s been really, really challenging. Even in my nursing home, we have a sharp cut to the census and lost a lot of folks as a result of COVID this year.
Jen: It’s tragic. So, moving forward, what do you envision going forward in terms of how you divide your clinical time with your consulting time and how you manage your work-life integration?
Lisa: Yeah. So, I think I’m at that place in my career where if it’s not fun or meaningful, I don’t want to do it. [laughs] I’ve definitely had plenty of years of very long hours, and nights, weekends, seven days a week, on call, off call, the whole gamut. I think I’m at that place right now where if it is fun or meaningful, it creeps to the top of the list and gets stratified a bit higher. In my future work, my heart’s desire is, like I said, to really improve the system a bit more and try to do that through some policy changes or some bigger system regulations in the sense to create better balance for people, and not just us as a workforce, but also for our patients to have a better patient experience through the system, and hope to help us address their needs in a more holistic way. Social drivers of health are incredibly important and really matter.
In primary care, I know that a significant percentage of the prescriptions I write may never get filled and patient education, literacy, financial education around costs of medications, and especially, in the older population, where I love to be with my clinical work. I do a lot of negotiating. When I’m thinking about starting a new medication and is it a brand name, are they in the doughnut hole, what is their coverage like, do they have a Part D plan? It becomes incredibly challenging to help that patient on that journey.
Jen: That’s an area where I could see having some depth to your team with a PA could make a huge difference from the patient’s perspective.
Lisa: Yes. And also, using pharmacists on teams, I’ve done that as well. If it’s a big enough group, and they can afford a pharmacist, especially, in the long-term care setting or in a small hospital setting, it’s just invaluable, the breadth and depth that the team creates by bringing those interdisciplinary collaborative experiences.
Jen: Absolutely. I’ve experienced that as well. It makes such a richer team for the ultimate outcome for the patient and a better patient experience as well because they can have so much more time with their clinicians.
Lisa: Yeah.
Jen: Well, Lisa, thank you so much for coming and talking with me. I’m really excited to talk with you in the future more about the work-life balance question, because I think from the conversations we’ve had, I’m very curious about the PA perspective, and I think PAs have some insight that you guys can share with us, and we can learn from you.
Lisa: Yeah, thank you. It was interesting. I spent a bunch of years on the admissions committee for the PA program, and it was always interesting to hear why do you want to be PA, why PA and not physician? And work-life balance was right there at the top. It was definitely an answer that we heard a lot and a very deliberate choice on the part of many bright young folks who were looking to get into healthcare.
Jen: Absolutely. And that’s food for thought for anyone out there who is making that decision. So, we’ll come back and revisit that question in the future and revisit DocWorking Thrive for PAs, which we’re talking about. Thank you so much for coming to be with me on the podcast today.
Lisa: Thank you for having me. I really appreciate it.
[DocWorking theme]
Jill: Let’s face it. Sometimes, in medicine, leaders end up in their positions because of their achievement, not because of their leadership skills. If you’re in medicine, and you’re a leader and you want to improve your skills, or perhaps you’re a physician who would like to be a leader someday, if either of those things are true, then you need to hire a physician leadership coach. Somebody with lots of experience working with physicians to help them identify what kind of a leader they want to be, help them implement a plan to become that leader, and to help them leverage their strengths, so that they can be the best they can be in a leadership position.
Amanda: I’m Amanda Taran, producer of DocWorking: The Whole Physician Podcast. Thank you for being here. Please check us out at docworking.com. And please don’t forget to like and subscribe. Thank you for listening.
