Questions for Current NPs

[JesseMJ]

Hi All,

I'm new to the site and have found it quite informative so far. I am applying to several accelerated MSN programs this fall, as well as 2 accelerated BSN programs. I have a strong interest in cardiology as an area of focus. To help with the decision-making process, I wanted to ask a few questions of some current Nurse Practitioners:

• Do you feel being a NP is a lot more rewarding than having a regular BSN degree?
  
• How are the opportunities for doing research or working in, say, a cardiology practice?
  
• Do you feel that having an advanced nursing degree will be increasingly important in the future?
  
• What does having an MSN allow you to do that you can't do with a BSN?
  

Thanks for any info you can provide. I've done some searching on the forums and FAQ sections, and found there is a big debate about accelerated programs. I've read a lot about both sides, so I won't begin to get into that whole argument. Thanks again.

Jesse

[Corey Narry, MSN, RN, NP]

I'm happy that you're working for a hospital that pays NPs more. But that is not typical. Most private hospitals have a hard time justifying NPs. The reason is as I stated: MDs are not on the payroll and cost the facility nothing. Why should they hire an NP and pay them $10k per month when they don't need to?

Hospitals that are run by private corporations provide priviledges to physicians in private practice to admit patients. You are right, these physician's salaries are paid by the insurance companies directly not by the hospital (the hospital gets reimbursed by the insurance companies for the hospital care provided to the patient). These places traditionally do not hire PA's and NP's as employees but rather, the private practice physicians employ their own PA's and NP's as part of their private practice. The salaries of these non-physician providers are at the mercy of the employing physician group and are not subject to the same salary range that hospital employees get.

I work for a hospital that hire their own physicians and employ them on their payroll (i.e., Kaiser, UCSF, Stanford). These places traditionally hire NP's and PA's as well and because they are also part of the payroll, they are subject to the hospital's salary ranking for all employees. This is where an NP can make more than an RN because the salary ranges are adjusted according to role. If you have time, look up the NP salaries at Kaiser facilities and see for yourself how much more they earn.

The reality is that California has a potential workforce of over 15,000 NPs and we don't even have a defined scope of practice. NPs in California are dependent upon someone paying them - it is very difficult to be in private practice. I'm not talking about new grads - I know a number of experienced RN/NPs who make more as an RN than as an NP - so they don't work as NPs - and why should they? The nearly 400 bed hospital I work at as an RN pays its 2 experienced NPs about $10k less than I make.....

The scope of practice has little to do with securing employment as an NP. NP's can bill Medicare and MediCal directly as is the case in the other 49 states. California requires a Standardized Procedure document and a Furnishing License for NP's to perform the roles traditionally held by physicians. As long as these are in place, there really isn't much Califonia NP's can not do that NP's in other states are already doing. Northern California, particularly the Bay Area is a heavily populated region that is also saturated with professionals including many physicians (3 medical schools are located in this region - Stanford, UCSF, UCD).

The jobs are just not as abundant as other regions where there are less competition between providers. This is ripe for a situation where a nurse pracititoner would take a job that pays less than an RN just so they can practice as NP's. The two NP's you mentioned are likely employed by private practice physicians, not the hospital you work for. That is a choice an individal makes and if they are happy with that arrangement so be it. I am also not judging NP's who choose to work as RN's because they can earn a higher salary that way. I just happen to prefer working as an NP and luckily I work for a hospital where I earn more than the bedside RN's.

If you work for Kaiser its a different story - Kaiser has to pay its docs - nobody else does.....

Not true...UCSF, Stanford employs its own physicians

[CCRNDiva, BSN, RN]

Juan, you are quite right. Many, if not most teaching hospitals employ their physicians and many private hospitals are trending that way as well. Cleveland Clinic, which has been identified as a model hospital for the future of healthcare, employs all of their practicing physicians. I am pretty sure U of Chicago, Northwestern and Loyola employ their physicians as well.

I work in an 400 bed private non-profit hospital and our hospitalist practice has tripled over the past couple years. Our hospital has also started a pediatric hospitalist practice as well. The majority of our physicians in our area are no longer independent and now belong to either of our two hospital systems (many of the specialists remain in private group practice) .

Most NPs here either work for the hospital's medical group or are employed by a private group practice. Our hospital recently began employing NPs for inpatient roles and yes, their pay is pretty low (around $65,000). The only RNs making that much in our area have been RNs for 25+ yrs or are in administration. The crazy thing is that the hospitals changed their pay scales and eliminated clinical ladders years ago so that RNs like me (7+ yrs) will never make it to that pay grade. So $65,000 is paltry for a NP but it is more than I make now. (Don't worry, I don't plan on staying in this area much longer, lol!)

[Corey Narry, MSN, RN, NP]

Juan, you are quite right. Many, if not most teaching hospitals employ their physicians and many private hospitals are trending that way as well. Cleveland Clinic, which has been identified as a model hospital for the future of healthcare, employs all of their practicing physicians. I am pretty sure U of Chicago, Northwestern and Loyola employ their physicians as well.

I work in an 400 bed private non-profit hospital and our hospitalist practice has tripled over the past couple years. Our hospital has also started a pediatric hospitalist practice as well. The majority of our physicians in our area are no longer independent and now belong to either of our two hospital systems (many of the specialists remain in private group practice) .

Most NPs here either work for the hospital's medical group or are employed by a private group practice. Our hospital recently began employing NPs for inpatient roles and yes, their pay is pretty low (around $65,000). The only RNs making that much in our area have been RNs for 25+ yrs or are in administration. The crazy thing is that the hospitals changed their pay scales and eliminated clinical ladders years ago so that RNs like me (7+ yrs) will never make it to that pay grade. So $65,000 is paltry for a NP but it is more than I make now. (Don't worry, I don't plan on staying in this area much longer, lol!)

Certainly a lot more to think about when it comes to practice models as a nurse practitioner. Nurses at the bedside have a more streamlined employment process especially those who work in acute care settings. Fortunately, many NP programs are good at providing courses in the economics and business of healthcare especially focusing on the regulations surrounding reimbursement, privileging and credentialing, contract negotiation, risk management, etc. Though these courses fall into the "fluff" category, they are actually essential in practice because these are things we never learn as bedside nurses.

[TheOldGuy]

Juan,

I think you'll find that the hospital itself is a separate and distinct entity from the physicians that you think are "employed" there. You'll also find that those physicians/physician groups are billing separately for their services. The hospital doesn't pay them - insurance/medicare/medi-cal does....as an example Kaiser docs are separate from Kaiser hospitals...check it out.......

[Corey Narry, MSN, RN, NP]

Juan,

I think you'll find that the hospital itself is a separate and distinct entity from the physicians that you think are "employed" there. You'll also find that those physicians/physician groups are billing separately for their services. The hospital doesn't pay them - insurance/medicare/medi-cal does....as an example Kaiser docs are separate from Kaiser hospitals...check it out.......

OK, those are semantics. Kaiser Permanente is a huge corporation that owns the Kaiser Permanente Hospitals and Clinics, the Kaiser Permanente Health Insurance Plans, and employs physicians through the Kaiser Permanente Medical Group. The medical group bills for the physician's services and pays the physicians a salary. The medical group also bills for the services NP's provide and pay the NP's the same way. Providers do not bill separately in this kind of model -- that is double dipping and is illegal.

This is not an unusual model. This IS the model used by Mayo Clinic, Cleveland Clinic, and many others including a hospital I worked in for 7 years in Detroit, Michigan called Henry Ford Hospital (part of the Henry Ford Health System which owns the hospital, the medical group, outpatient clinics, and a PPO/HMO). I am not new to this practice arrangement.

Academic medical centers employ their own physicians though not all of them follow a strict closed academic medical group model. UCSF and Stanford follow a closed academic medical group model. Physicians are hired in as faculty members of the medical school and can only work for either UCSF or Stanford. San Francisco's county hospital and trauma center (SFGH) is staffed by UCSF physician faculty as well. The VA facilities are the same way, they are either hired by the VA or jointly appointed as faculty members of the affiliated medical schools.

[TheOldGuy]

Juan,

The issue is not just semantics - its funding. Because of the structure, the separate physicians groups are being paid by outside sources and are not truly cost items to the hospital. In contrast, with NPs, the NP IS typically a hospital employee and is a cost to the hospital. This gets back to my point as to why hospitals are not hiring NPs - why should they when they are a cost item to the hospital when equivalent or higher level services are provided by physicians at no cost to the hospital. The groups that hire NPs are paying NPs as little as possible because the NPs are a cost to them - not revenue generators the way they see physicians...its all about the money......:smokin:

[Corey Narry, MSN, RN, NP]

Juan,

The issue is not just semantics - its funding. Because of the structure, the separate physicians groups are being paid by outside sources and are not truly cost items to the hospital. In contrast, with NPs, the NP IS typically a hospital employee and is a cost to the hospital. This gets back to my point as to why hospitals are not hiring NPs - why should they when they are a cost item to the hospital when equivalent or higher level services are provided by physicians at no cost to the hospital. The groups that hire NPs are paying NPs as little as possible because the NPs are a cost to them - not revenue generators the way they see physicians...its all about the money......:smokin:

What you are missing is the fact that NP's generate revenue because NP's bill insurance companies for their services just like physicians do. This is a fact in all 50 states. NP's have a National Provider Identifier Number used to bill CMS (Medicare, MediCal) and other insurance companies. Services provided by an NP that fall under Evaluation and Management (Admission H&P's, Daily Progress Notes) as well as any bedside procedure performed by NP's have a corresponding cash value that hospitals (or a private practice group whichever the case is) can bill for. Nurses who are not APN's do not bill, hospitals are able to provide salary to nurses from revenue obtained from payments collected from the hospital bill the same way other non-providers (including housekeepers) are paid.

[core0]

Juan,

The issue is not just semantics - its funding. Because of the structure, the separate physicians groups are being paid by outside sources and are not truly cost items to the hospital. In contrast, with NPs, the NP IS typically a hospital employee and is a cost to the hospital. This gets back to my point as to why hospitals are not hiring NPs - why should they when they are a cost item to the hospital when equivalent or higher level services are provided by physicians at no cost to the hospital. The groups that hire NPs are paying NPs as little as possible because the NPs are a cost to them - not revenue generators the way they see physicians...its all about the money......:smokin:

What you are describing is what happened in the late 80's or early 90's. Hospitals would hire NPs or PAs and bill for their salaries under part A. This is now illegal. NPs bill under Medicare part B just like everyone else. Where it gets tricky is the interaction of Stark and medicare billing. A number of hospitals have paid large fines for Stark violations when they hire NPs to provide services for physicians and then the physicians bill for the services. Other hospitals have been caught when they hire and bill for NP services on a physicians patient without a clear indication the NP is the physicians employee (essentially double dipping). Thats not to say that hospitals that don't have a clue about billing aren't trying to do this.

This goes back to what Juan was saying. At most Academic medical centers there are three legally separate groups. The hospital, the practice group and the medical school. If University of Colorado for example there is University Physicians Incorporated which bills for physician services, University of Colorado Medical Center and University of Colorado Medical School. The physicians (and to some extent NP and PA) salary is made up of money from the medical school either in regards to research or teaching, money from the hospital to cover call or other services such as medical director of a unit and money from UPI for services billed. When the hospital hires an NP and tries to bill for them when covering or rounding on the physicians patient you have a case where the NP works for one group and the physician works for another which is legally a no-no.

[nomadcrna, DNP, CRNA, NP]

Juan is correct. NP bill should be billing under their own NPI. NPs MAKE money for organizations

What you are missing is the fact that NP's generate revenue because NP's bill insurance companies for their services just like physicians do. This is a fact in all 50 states. NP's have a National Provider Identifier Number used to bill CMS (Medicare, MediCal) and other insurance companies. Services provided by an NP that fall under Evaluation and Management (Admission H&P's, Daily Progress Notes) as well as any bedside procedure performed by NP's have a corresponding cash value that hospitals (or a private practice group whichever the case is) can bill for. Nurses who are not APN's do not bill, hospitals are able to provide salary to nurses from revenue obtained from payments collected from the hospital bill the same way other non-providers (including housekeepers) are paid.

[nomadcrna, DNP, CRNA, NP]

More and more hospitals are hiring providers (physicians as well). It is becoming the norm in many parts of the country. The physicians are EMPLOYEES of the hospital or of a hospital owned group.

Juan,

I think you'll find that the hospital itself is a separate and distinct entity from the physicians that you think are "employed" there. You'll also find that those physicians/physician groups are billing separately for their services. The hospital doesn't pay them - insurance/medicare/medi-cal does....as an example Kaiser docs are separate from Kaiser hospitals...check it out.......

[nomadcrna, DNP, CRNA, NP]

I'm not trying to be an ass and correct me if I' wrong.

Is OldGuy a NP? Or is he still an RN student.

I'm amazed at people assuming things and opining on issues they really have no knowledge of.

As Juan pointed out in a much nicer way, the below is simply NOT true and shows a lack basic lack of knowledge in regards to NP.

The same with the distinct entity thing. It is common knowledge that more physicians are becoming employees instead of private practice.

But the fact remains that both NP and physician bill for their services.

"In contrast, with NPs, the NP IS typically a hospital employee and is a cost to the hospital. This gets back to my point as to why hospitals are not hiring NPs - why should they when they are a cost item to the hospital when equivalent or higher level services are provided by physicians at no cost to the hospital."

[TheOldGuy]

Guys,

Let's stop accusing people of not knowing what they're talking about - I never accused anybody of not knowing what they're talking about - what I did state, was what practices I'm seeing at facilities I'm familiar with. Those are Kaiser and CHW specifically. While NPs may have the legal ability to bill, it doesn't mean they are allowed to by their employer. In some locations, the NP is independent. Not so much in California. This whole discussion was generated by my views of why NPs are not making the kind of money they should be. Laws vary by state. Facilities vary in their practices. If everything you guys are saying was universally true, then NPs around here would be making a great deal more. What I'm saying is that because of some oppressive legislation that is designed by the California Medical Assn to protect physicians and their incomes, NPs are not making the incomes they should be and consequently California is not very NP friendly. California does not even have a defined scope of practice for NPs. Instead NPs must work under standard orders - at the control of a collaborating/supervising physician. The point I made about NPs being a cost item and not revenue generating is a direct quote from the Director of Nursing at the facility I'm at. Thats why they are contracted with hospitalist groups who cost the facility nothing. The highest paid NP at my facility makes about $125k and is salaried. As an RN I make about the same on base pay and a lot more with OT. Which again goes back to my point about how NPs are underpaid. In our ER we have 2 other NPs who work strictly as RNs because they make more than the company who our hospital contracts with for ER medical services is willing to pay NPs.

If you want to attack me for telling you what I'm seeing then go for it. My point is simply that NPs are underpaid and underutilized in California due to the power of CMA and the weakness of CANP. I recently quit CANP out of frustration with their lack of action on issues like scope of practice/independent practice.

I wish I was as wrong as you all seem to think I am.......we would be making a lot more money as NPs!