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]

22 hours ago, myoglobin said:

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).

It doesn't include differential. That's base pay. Travelers would get cancelled first before regular staff in any hospital in Northern California but I can see how Kaiser would play aggressive about it given that their regular nurses have strong CNA representation.

[myoglobin, ASN, BSN, MSN]

My friends have been told by their travel agency contact that Kaiser is particularly aggressive about canceling contracts. As a travel nurse this is not optimal especially if you are someone who obtains their own housing (given that you are often bound to an area for one-six months) by a housing contract.

[myoglobin, ASN, BSN, MSN]

38 minutes ago, TitaniumPlates said:

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.

My previous discussion was in the context of moving as an RN (travel assignment). This is in the context (primarily) as an NP (specifically PMHNP). The discussion is intended to be useful not only to myself, but also to others. Only in the last few weeks have I had access to specific details about jobs (potential offers) relating to PMHNP positions for a new grad (me). Please do not mistake discussion for "shooting something down". I believe that debate/discussion can often highlight different perspectives and illuminate new perspectives not previously considered. For example I have learned (as have others potentially) from this discussion that California can be "achieved" at least theoretically in a time frame far more reasonable than I had previously thought possible. Also, we have learned that the furnishing aspect can be achieved at the same time as other steps. Had I not posed the question(s) this would not have been brought forward for myself and others. There are potentially dozens of other useful details about the varied nature of the NP practice environment just waiting to be illuminated if only the right person participates in this discussion. Again, this is meant not only for my benefit, but for the sake of others in the present and future. I intend to be an ongoing resource for anyone seeking to become or maximize their opportunities as an NP.

[myoglobin, ASN, BSN, MSN]

Also "Titanium Plates" I have been a member here for many years and my "autistic style" has little changed. That is to say I explore (perhaps you would say debate) a subject until there are few (if any) other perspective(s) or points that can be made (I am the same way in my personal life just ask my SO I might spend a decade debating the points for moving to Hawaii). No doubt many find this annoying and I would encourage those individuals to pursue threads that they find less irritating.

[FullGlass, BSN, MSN, NP]

5 hours ago, TitaniumPlates said:

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.

You are correct that air quality in the Central Valley (San Joaquin Valley) can be bad at times. I would not recommend it for people with respiratory conditions. However, millions of people live there. I have mild asthma and have been living in the North State and spending a lot of time in the Central Valley for over a year, with no problems.

With regard to water, there is no evidence that the Bakersfield water has harmed anyone. In addition, most people in California drink bottled water - I always have, no matter where I have lived - San Diego, LA, Bay Area, and so forth.

Fresno is indeed a lovely city, as anyone who has actually been there can attest.

Bakersfield is growing very rapidly now, with 850,000 people in the general metro area. As with any large city, there are good and bad areas. Air quality can be bad at times, but it is not bad all the time. Pretty much any big city is going to have bad air quality at times. Honestly, name me one big city that has pristine air.

https://www.washingtonpost.com/

https://bakersfieldnow.com/news/local/bakersfield-leading-the-state-in-population-growth

https://www.forbes.com/pictures/eihe45hhl/19-bakersfield-ca/#29333bda40a7

https://norcalapa.org/2019/07/bakersfield-is-booming-as-are-many-other-inland-california-cities/

https://www.sfgate.com/expensive-san-francisco/article/bakersfield-popular-millennial-home-buying-cities-13799411.php

The Central Valley is not on fire, so I don't know where you are getting your information. Big fires do not occur on farmlands. When the crops are growing, the land is well-irrigated. After harvest, the fields are plowed under and are nothing but bare dirt. Orchard trees remain, of course, but there is no underbrush. Some grass might grow, but not enough for a significant fire. The fires in California are in areas with very heavy overgrowth of brush and/or trees. Many of these areas border forests.

I am moving to Sacramento, which is in the Central Valley. I grew up on the beach and I am tired of people bashing the Central Valley. There is a severe shortage of providers there. So the pay is great and housing is very affordable. In addition, patients are sincerely grateful and appreciative of providers.

In the Central Valley, there is such a shortage of neurologists that post-stroke patients can wait up to a year to receive follow up care. UCSF is adding teaching facilities to a major hospital in Fresno, which should increase the supply of providers. The only major academic teaching hospital in the Valley now is UC Davis.

Personally, I was bummed that I had to turn down a great offer in Bakersfield for $150K the first year, $160K the second year working for a very nice doctor with a great training program. Given that I could buy a nice house there with a swimming pool for around $250K to $300K, I'd say the pay was great and I only have a little over one year of experience. There is a lot of new construction, with big wide roads, lots of shopping, and very nice areas that are clean and well-maintained.

The Central Valley has a very large underserved patient population. This is a chance to do some real good, as well as opportunities for HRSA and Nurse Corps Scholars, chance to apply for state and federal loan repayment. Ethnically and racially, the area is very diverse, with large populations of Hispanics, East and South and Southeast Asians. There are many clinics that help migrant farm workers, the homeless, and so forth. If you need or want to work in an area with a large underserved population, well you aren't going to be in Beverly Hills or La Jolla. So if you want to make a real difference, then here is your chance.

There is no "perfect" place with great weather, no taxes, low cost of living, perfect air and water, great schools, and no crime. You have trade offs.

[FullGlass, BSN, MSN, NP]

5 hours ago, myoglobin said:

The discussion is intended to be useful not only to myself, but also to others.

I agree and found the discussion informative. Thank you.

[Tony1790, BSN, MSN, NP]

Of your top three choices Washington, Oregon, California, I would pick Washington, as there is no state income tax, there are cheaper parts of the staDo you live in beside Seattle, Oregon has approximately 10% income tax, and California is approximately 12 to 13% income tax so you would need to make an extra 12% in California to make the same in Washingtonte Do you live in beside Seattle, Oregon has approximately 10% income tax, and California is approximately 12 to 13% income tax so you would need to make an extra 12% in California to make the same in Washington

[myoglobin, ASN, BSN, MSN]

I talked to a psychiatrist in Oregon (Eugene) today who pays 55% and will give $5000.00 zero interest loan every month for the first three months while you are building up a clientele and awaiting insurance reimbursement. I would have complete control over my appointment window times and the days that I worked. He said that most PMHNP's who do 20 minute appointments earn around 240K,, but it drops down to about 150K for 30 minute medical management appointment length(s). He seems like an amazing psychiatrist, but he was skeptical that any place was offering 70% (as several have in Seattle). I think that the primary reason that the Washington clinics offer this is that they are counselor own/run. Like the one in Fort Collins Colorado which is offering 60% (65% in the second year). Thus, they have maybe 15 to 20 counselors and having a couple PMHNP's is more of a "service" to the clinic's existing patrons than a "profit center". The Seattle places also talk about having so much business that at least half their clinicians accept cash only (this is the only place I have come across, where this seems to be common). Contrast that to his clinic which has four or five PMHNP's ( and two psychiatrists) and two counselors. In essence, it is the "counselor owned/ led" approach which may generate a higher percentage for the NP. Any thoughts on this hypothesis? Also, Eugene sounds really nice (warmer than Seattle) but 10% (state income) puts a bit of chill in the air. I could still indulge my childhood fantasy of "seeing Bigfoot" in Washington couldn't I?

[FullGlass, BSN, MSN, NP]

41 minutes ago, Tony1790 said:

Of your top three choices Washington, Oregon, California, I would pick Washington, as there is no state income tax, there are cheaper parts of the staDo you live in beside Seattle, Oregon has approximately 10% income tax, and California is approximately 12 to 13% income tax so you would need to make an extra 12% in California to make the same in Washingtonte Do you live in beside Seattle, Oregon has approximately 10% income tax, and California is approximately 12 to 13% income tax so you would need to make an extra 12% in California to make the same in Washington

Incorrect. The California state income tax has brackets which are highly progressive. You are quoting the highest MARGINAL tax rate which only applies to income OVER $572,000.

For single and married/registered domestic partners filing separately:

1 percent on the first $8,544 of taxable income

2 percent on taxable income between $8,545 and $20,255

4 percent on taxable income between $20,256 and $31,969

6 percent on taxable income between $31,970 and $44,377

8 percent on taxable income between $44,378 and $56,085

9.3 percent on taxable income between $56,086 and $286,492

10.3 percent on taxable income between $286,493 and $343,788

11.3 percent on taxable income between $343,789 and $572,980

12.3 percent on taxable income of $572,981 and above

A 1 percent surcharge, the mental health services tax, is collected on taxable incomes of $1 million or more, making California’s highest marginal rate 13.3 percent.

For married people filing joint returns and heads of households, the rates remain the same, but the income brackets are doubled.

https://www.bankrate.com/finance/taxes/state-taxes-california.aspx

[FullGlass, BSN, MSN, NP]

44 minutes ago, Tony1790 said:

Of your top three choices Washington, Oregon, California, I would pick Washington, as there is no state income tax, there are cheaper parts of the staDo you live in beside Seattle, Oregon has approximately 10% income tax, and California is approximately 12 to 13% income tax so you would need to make an extra 12% in California to make the same in Washingtonte Do you live in beside Seattle, Oregon has approximately 10% income tax, and California is approximately 12 to 13% income tax so you would need to make an extra 12% in California to make the same in Washington

While I agree with you on picking Washington, taxes are not so simple. I've addressed income tax and marginal rates. Property tax is higher in both Oregon and Washington. Given the Oregon tax brackets, an NP could pay more in Oregon income tax than in California. Oregon has no sales tax.

Personally, I think the best option is to live on the Washington-Oregon border, live and work in WA, and shop in Oregon.

[myoglobin, ASN, BSN, MSN]

I agree that makes sense. Although, from a practical standpoint I don't have any likely offers from around the Oregon/Washington border. The cities where I might get offers (Seattle/Everett, and Eugene Oregon) are too far from the borders to employ your approach. Frankly, given that I'm still earning about $43.00 hr as an RN (working PRN) I'm not going to quibble over taxes too much and am going to focus on the best practice environment, reputation of the company and opportunity (although rates approaching 8% or more of my overall income in state taxes are significant especially when combined with the increased tax burden of being paid 1099). Things like the Fort Collins therapist led practice having a 4.8 Google review on almost 200 reviews I find impressive considering that most places down here in Florida are lucky to hit 3.0 on Google reviews and many hover in the low 2's. Also the fact that they have hundreds of clients waiting for medication management appointments (currently seeing their therapists) is somewhat compelling. Property taxes are not quite as much of an issue since I will be renting the cheapest two bed room apartment or Airbnb that is safe, and has good wifi that I can find. Ironically, places like Seattle that is very expensive from a housing standpoint has some long term Airbnb's in the $1000-$1200/month range (no lease). While less expensive areas (like Eugene) seem to have higher AirBnb prices.

How about the question of "therapist lead" practices paying more (as percentages). I've encountered this with two practices in Washington (80% and 70% with some monthly fees totaling about $600.00 so the effective rates might be more like 75% and 65%). Also a therapist lead practice Fort Collins Colorado that pays 60% the first year and 65% the second (I think he said 70% the third year). There was even a therapist "co led" (with an MD partner) practice in Florida (I interview there this weekend) that talked about 60% with a 90K base guarantee (paying a percent to NP's in Florida is truly rare). However, almost all of the MD lead practices offer mainly a salary ( some with possible bonuses). The two MD lead practices that pay percentages were one in Phoenix (50%, but they want 15 minute appointments almost like Florida) and the MD/psychiatrist that I talked to today in Eugene (55 or 60% I can't quite remember which). Also the MD lead practices might feature a few counselors, but the counseling lead practices generally have more than 10 counselors and are looking to add or augment existing prescribing services. I wonder is there a more formal/scholastic name for these different practice models? and not to muddy the waters further, but I've encountered only a few PMHNP led practices but having not received any job prospects from those don't have any data points as to where they fall in the mix in terms of pay and approach.

[wizard100]

Arizona and WA state are best considering pay and NP culture/independence. I've worked in central California as a NP-summers are just nasty-hot/humid and tax is high. WA starting pay is good but it stalls- hard to get pay raise on merit. Living expenses can be just as high as California and property taxes are high. Arizona has best NP culture, autonomy, independence, and pay is good/ living expense is cheap. With that said, I am a FNP working in Seattle making 145K per yr with PTO, holiday pay, 401K, paid CME, paid license renewals. The only thing I dont like living here is from Mid october to March/April-gloomy, dark showery short days. People can get SAD, depression easy. Twilight movies were shot here-its like vampire living city during those months. Traffic is bad too. Summers and springs are one of the best in the country. 70s-80s overall. Hardly 90s...if it does its only couple of days.