Best States for RN's and NP's both in terms of pay and practice?

[myoglobin]

So as a new grad. PMHNP I'm considering leaving Florida. My SO has been practicing "here" since 2016, but she entered the profession with a telepsych job paying $85.00 per hour and these jobs now seem to want a minimum of two years experience to even be considered. Based upon the 500 or so jobs nationwide that I have applied for here are my impressions of the best pay and practice for NP's. I will throw in RN for good measure based upon past experience.

NP's

1. Washington State- Good pay, good practice environment, independent practice. Good climate and good natural beauty. Also no state income tax.

2. Oregon. Same as above, but the pay for NP's may be slightly less. No sales tax.

3. Nevada- Same as above, but you need 2000 hours (I believe for IP practice). No state income tax.

4. Pay may be as good as Washington state, but the practice environment is worse. Shorter appointment times (for medical management) . The rule seems to be 20 minutes rather than the "Washington 30, standard". Less of a chance that Medicaid patients will get therapy. Partial hospitalization, art therapy, ACT teams are relatively rare (compared to Washington).

5. I'm going to put New York State out there. Yes their state income tax is horrible, but their practice environment in terms of Medicaid services, and pay seems to be excellent. Upstate the cost of living isn't bad either and it is quite scenic. On the other hand maybe someone might make a better case for New Hampshire which also has IP (unlike New York) and no state income tax.

For RN's.

1. California- The only state with ratio laws "with teeth" and really good pay despite high cost of living.

2. New York State- Strong nursing unions (albeit no strong ratio laws). Really good pay.

3. Nevada. I seem to remember that they had the best RN pay when adjusted for cost of living. Also no state income tax.

4. Washington. You are in a great state to become an NP if nothing else. Also, I believe the RN pay is decent.

5. Mass. I keep hearing that the hospital environment is top notch for RN's and the pay really good.

I would be interested in some diverse perspectives on this list. Keep in mind my NP list is largely from a PMHNP perspective and other NP's (such as FNP's) may differ.

[Corey Narry, MSN, RN, NP]

It's not impossible to live in expensive areas of CA as an NP. I own a home in the SF Bay Area and work right in SF. I moved here 10 years ago from the Midwest. It can be a culture shock and you must be able to accept trade-offs and be willing to overlook those "uniquely California" ways such as living in smaller homes, long commutes and traffic, liberal politics, and high state taxes for the opportunity to live in naturally beautiful scenery with very little weather variation or extremes, plenty of recreational activities within driving distance, cultural diversity in every aspect, and good medical facilities that attract talented individuals across the US. Those things I consider perks can be subjective and you may absolutely hate it here so it is certainly not for everyone.

[myoglobin, ASN, BSN, MSN]

Just a few points of clarification (typed from I phone after a miserable ICU night w/o sleep)

a. I think California is number one for RN’s period. Their ratio law is a game changer. Just come to Florida and get tripled in ICU or get six really sick PCU patients and you might agree.

b. California is still good for NP’s, but perhaps not for someone who owes a great deal of student loans looking to start working as a PMHNP soon. Also my SO will probably not move with me as she wants to remain in Florida for our son who is starting college. Thus I will be responsible for 1600 rent in Florida plus my living expenses wherever I work. Hopefully, she will visit once a month or so since she can work from anywhere.

c. There are some NP independent practice states that do not have experience requirements by law. Examples that come to mind include Arizona, Washington, Oregon, Maine, Hawaii, Wyoming, New Mexico, Idaho, and Nebraska, and New Hampshire, to name some off the top of my head.

d . I have had some potentially lucrative prospects (but not yet firm offers) from places not in California. Examples include:

a A place in Seattle offering 70 percent of gross receipts minus $600.00 per month for front office and billing support. They also would charge about $2000.00 in credentialing fees but state their current PMHNP gross form 160-240 working 3 or 4 yen hour days (I would do 5 10’s initially).

b. A place in Bellingham Washington offering $100 hr W2 with benefits. They would also consider my SO who has been a PMHNP since 2016 and only earns 85 hr 1099 in telepsych from home.

c. A job in Phoenix that would pay $100.00 hour 1099 working from their office up to 50 hours per week.

d My SO’s company has a 1099 Arizona telepsych job in Arizona ( but I would work from home like her) paying 85 hr.

e. A job in Plattsburg New York flying me in for an interview that would pay me 170k with good benefits at a top notch community health facility.

f. A TMS position in Portland offering about 150k with benefits.

g. A position in Fort Collins Colorado with a company owned by counselors that would pay 60 percent the first year and five percent more each additional year of gross receipts up to 70 percent and no other fees. They say they have about 400 clients waiting to be seen. They also have experienced PMHNP’s and psychiatrists who will do the 1000 hour Colorado mentor ship requirement.

h. A position in Melbourne Beach Florida that would pay 60 percent 1099 of receipts with no other fees and a 90k base guarantee. They say most of their NP gross about 6500 every two weeks. They also provide 20 minute medical management follow ups where 15 has become quite common in Florida. Note also that the other opportunities above do 30 minute medical management windows.

i. A local job that would involve seeing Medicaid, Medicare, and foster clients for a non profit that would pay 60 per medical management appointment and 100 per assessment minus 8 percent to a collaborating psychiatrist. They have 300 clients waiting to be seen and 300 more in services. Appointment times would be 50 minute for initials and 30 minute for med management. Not bad for Florida.

j. I have about 10 other prospects ranging from 130k to 150k in states like Maine and Wyoming all W2.
Thanks for the input.

[Thanksforthedonuts, MSN, APRN]

Myoglobin, I find Your info very helpful and exactly what I have been looking for. I graduate PMHNP in a little over 2?years from now and I live on Seattle’s east side (Bellevue/Kirkland). Have you noticed a huge difference in pay between primary care, independent offices, and acute care? I looked into an acute care position at a hospital nearby and they were offering $125K salary for new grads ?
I was not happy to hear that as I know they were DESPERATE for a provider. Maybe they were just low balling me to see my response. The Eastside area of Seattle is EXPENSIVE and the high cost of living doesn’t make that salary amount sound enticing in the least.

[Thanksforthedonuts, MSN, APRN]

Myoglobin, I find Your info very helpful and exactly what I have been looking for. I graduate PMHNP in a little over 2?years from now and I live on Seattle’s east side (Bellevue/Kirkland). Have you noticed a huge difference in pay between primary care, independent offices, and acute care? I looked into an acute care position at a hospital nearby and they were offering $125K salary for new grads ?
I was not happy to hear that as I know they were DESPERATE for a provider. Maybe they were just low balling me to see my response. The Eastside area of Seattle is EXPENSIVE and the high cost of living doesn’t make that salary amount sound enticing in the least.

[myoglobin, ASN, BSN, MSN]

I believe that FNP's are being paid less due to oversupply. This situation will also likely manifest with PMHNP (arguably it has since my SO was hired for her telepsych position in 2016 with almost a year to go in grad school with no pscych experience, they literally waited on her to graduate and then spent another six months credentialing her). Now, I am finding that most tele PMHNP positions want two years experience to be considered. The best way to mitigate this is in my opinion as follows:

a. Be flexible where you live. There will likely always be areas of greater need and therefore greater pay. Of course I say this as someone who has based his whole life around wanting to live in Kauai, and I'm no closer today than 20 years ago (at least geographically).

b. Get experience somewhere that will help mitigate against oversupply.

c. Get to an independent practice state where there is need and start your own practice (something that I currently cannot convince even my own SO is important). Offer hours that allow clients to see you without missing work (like evenings and weekends). This is especially important for ADHD children for whom missing school is even less optimal (to go to an appointment). If I had a mental health diagnosis it would annoy me to have to use PTO or sick days to visit my provider every couple of months and I would appreciate somewhere that I could be seen after work or on Saturday. Offer evidenced based complementary and alternative approaches. One example, there is good evidence for SAM-e as a mono-therapy or augmentative agent in MDD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5501081/ (but not in bipolar especially bipolar I as it may precipitate mania). There are meta-analysis suggesting that it may be as effective as tricyclic antidepressants without the negative side effects (sexual, weight gain, cardiac to name a few). However, 95% of psychiatrists (in Florida, perhaps less on the coasts) will dismiss the idea of using something like SAM-e. Thus, if you are someone who offers this treatment modality you effectively have something to offer not offered by the vast majority of your competition. Also listen to Podcasts like Dr. David Puder's Psychotherapy and Psychopharmacology podcast who emphasizes not only therapy approaches but holistic treatments that encompass diet, exercise, and sleep optimization. By following his example along with sources like the Carlat Report and the Psychotherapeutic Institute you ("we) may be able to offer excellent outcomes that encourage satisfied clients.

[guest769224]

6 hours ago, FullGlass said:

It has been discussed that there are RNs in the Sacramento area making $200K per year.

Would you mind providing any additional details on how this is achieved? I'm considering relocation to Sacramento for this very reason. I already work for one of the hospital systems there, although it's in a neighboring state.

[FullGlass, BSN, MSN, NP]

4 minutes ago, ICUman said:

Would you mind providing any additional details on how this is achieved? I'm considering relocation to Sacramento for this very reason. I already work for one of the hospital systems there, although it's in a neighboring state.

Well, that is the exception, not the norm. There was a thread here about Kaiser RNs in Sacramento making up to $200K per year because they are covered by the San Francisco contract and SF RNs make that. You can search for that thread.

Overall, California RNs can make excellent money, especially with overtime.

[myoglobin, ASN, BSN, MSN]

1. In short they work travel assignments like my friends Dave and Patty (husband and wife). For example their last assignment in the San. Fran area one took the housing paid for by the company, but then "only" earned about $35.00 hour. He took a higher wage of around $55.00 hour and also got a "housing stipend" of around $4,000 per month which is not taxed. At the same time they have a home in their home state that they could rent on AirBnb and earn an additional 2k per month or more. This is one common approach and Sacramental is probably one of the best areas to do this (along with San Fran, Fresno, and Bakersfield). Salaries will drop off a bit towards LA and even more toward San Diego (because next to Hawaii, it might be the most beautiful place to live in the United States).

[Corey Narry, MSN, RN, NP]

2 hours ago, ICUman said:

Would you mind providing any additional details on how this is achieved? I'm considering relocation to Sacramento for this very reason. I already work for one of the hospital systems there, although it's in a neighboring state.

I have access to Kaiser's Northern California CNA Contract (covers the San Francisco, San Jose, Oakland, Sacramento, Fresno areas).

For a Staff Nurse II to make 200K a year, you have to achieve maximum seniority and work overtime because their cap for that designation is $88.68/hr for a nurse with 31 years of seniority.

If I remember right, the post referred to involved a Charge Nurse. In the current contract, a Charge Nurse IV is capped at $100.57/hr for someone with 31 years seniority. So I think, the OP in that case is not giving us the entire story because you have to attain that much seniority at Kaiser to get that high of a pay scale.

Contrast that to Kaiser's NP salary which starts at $77.96/hr (NP I new hire) and maxes out at $111.73/hr (NP III with 31 years of seniority).

[myoglobin, ASN, BSN, MSN]

Does that include night and weekend shift differentials? For example I earn about 30% more by working nights and weekends (even though my hospital has since gone to a blanket $4..50 for nights and extra $3,50 for weekends I am grandfathered into the old percentage system). If not that would take someone up considerably. Also, my friends are earning travel "contract rates". Note that Kaiser is one of their last places they would choose to work because they have been told that Kaiser will aggressively cancel contracts relative to other hospitals in the area (although they also tend to pay better).

[Daniellenorth]

On 11/9/2019 at 10:03 PM, FullGlass said:

California hands down has the highest NP pay at $124K. Most of California is actually very affordable. The expensive cities/metro areas are San Francisco, Los Angeles, and San Diego. That leaves the rest of a very large and populous state as very affordable.

PMHNPs - new grad should start at at least $140K, likely to get $150K or higher (salary plus bonus).

California has a severe mental health provider shortage. It is especially acute in areas outside the 3 major coastal cities. There are quite large cities like Fresno, Bakersfield, Sacramento, Modesto, Stockton that are affordable. You can buy a small house in Bakersfield for $100K. There are also some very nice smaller cities like Redding and Chico. And there are lots of small towns and rural areas as well.

California does not have FPA, but NPs are pretty much treated as if they do. You're a new grad, so you are going to need supervision for awhile, anyway.

[TitaniumPlates]

18 hours ago, FullGlass said:

It depends on where you are living. No, less populated areas are not more expensive than other states. I have no idea where you are getting your information. I am renting a 2 BR 2 BA house with a yard for $800 per month. As I said, you can buy a small house in Bakersfield for $100K. You could buy a nicer house with a swimming pool and so forth for $250K. Given that NP pay is so much higher in CA, I still come out ahead. You actually make more money in California if you go inland, because there is a shortage of NPs.

As a primary care NP, first year comp $124K with the cost of living described above. Now, I am going to be starting my 2nd job with a little over one year experience. $150K base plus $6000 sign on plus there will be productivity bonuses, so I should make over $160K in my second year of practice as a primary care NP. If anyone out there thinks they can do better, please share.

It has been discussed that there are RNs in the Sacramento area making $200K per year. Sacramento is a bit pricey, but still reasonable. You can rent a nice apartment there for around $1000 per month, which is quite good for a big city.

With regard to FPA, that is an issue in California, but every year we get closer to getting it and it will happen, probably within 10 years. California NPs are treated like they have FPA in practice. And for a new grad, you're not going to get FPA no matter where you live, because even in states with FPA, there are experience requirements before it is granted.

Given that I constantly read on this forum about the crappy pay and lack of jobs in many parts of the US, it is kind of surprising that people want to complain about California, which has the highest pay for NPs and a great job market, with plenty of very affordable areas!

Fullglass, you're being either willfully deceptive or ...well....

Bakersfield is....not a good place to live if you like breathing clean air and drinking water uncontaminated by fracking fluid or other oil field pollutants.

Myoglobin, you have asked this question many times here and I can go back and pull up all of those threads, where someone suggests something and you shoot everything down.

My best advice to you is pull the thread up from 6 months ago, go over it again with a fine toothed comb, put your nickel down and make a decision.

If memory serves, your companion has no intention of leaving her position and there is a situation wih her kids as well. You kept hammering away at flying in to California and all that...and trying to game the system so that you can stay in...Florida?....and be paid big money, have low taxes, an easy caseload, and only work a couple days a week.

Nothing has changed from that epic thread until now.

California is on fire in the central valley. i moved from there when i had to wear an n95 to walk into work or walk my dog. bakersfield has a ridiculous level of respiratory diseases because of he oil fields. which is why its "so affordable". places like modesto, stockton, most of Sacramento, and the areas off of the interstate that are not big cities...are carbon copies of modesto.

It gets a little tired when the same question is posed by someone who has no intention of actually taking any of the advice, can't or won't, doesn't matter.

Blue states tend to have higher costs of living and taxes. red states have low taxes in some areas and lower cost of living...but each have their set of problems.

what is getting irritating for me is when people ask others what their opinions are and then shoot those opinions down ad infinitum.

Decide what you and your partner are willing to do and sacrifice for this "high paying, low work" job...and do that.