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.
Specializes in Psychiatric and Mental Health NP (PMHNP).
17 hours ago, SuziQ1978 said:
What about the state income taxes? That keeps me away from California. No Thank you.
Most NPs are still better off in California.
1. Our income and sales tax are high, but our property tax is pretty low. Our combined tax burden is high, but certainly not the highest.
2. I'm going to give a very simplistic example here.
Example 1 - Calif NP. $150K per year. Let's say 10% state income tax. So the net income is $140K per year.
Example 2 - Oklahoma NP - $100K per year. 5% state income tax. Net income $95K per year.
3. Cost of living is certainly a factor, but outside of San Diego, Los Angeles, and SF Bay Area, Calif is actually quite affordable in terms of housing. And the pay is actually higher outside of the coastal cities because the inland areas have a harder time attracting providers.
I heard an interesting radio bit from Dave Ramsay, king of thrifty living. He had a caller, a young man who had received a job offer in San Diego, making $150 K per year. The caller wondered if he could afford to live in San Diego. Ramsay laughed at him, saying of course he could! The average house cost was stiff affordable for his income level and since this appeared to be a great career opportunity, Ramsay told him he'd be a fool not to take it.
California has many good things going for it. As I have said many times when it comes to RN's it is the ONLY state that I would stay in "bedside" and still work within due to their strong union, ratio laws, and other perks. However, when it comes to NP's it is still good but has significant downsides. For example I manage many of my "simple" MDD patients with nothing other than SAM(e), multi vitamins (with extra B vitamins), Fish Oil and maybe something like Saint John's Wort (it it doesn't adversely interact with other medicines they might be taking. This is integrated with things like early morning sunlight, aerobic exercise, and yoga. Now in Florida I would be terminated in about a week at the majority of practices due to the conservative allopathic approach integrated with the strict supervision requirements. In California "who knows" I do need MD supervision, but as you pointed out it is probably all over the board. In Washington unless I am sued or have complaints filed against my license (that are deemed worthy) I can do whatever I feel is appropriate. Even Arizona is (which has full IP) is a considerably more strict with certain issues like strictly staying within your scope (for example I will sometimes use metformin for antipsychotic induced weight gain, but my wife who works in Arizona will not do this even though many sites like Psychopharm Updates advise this as a first line intervention when a client gains weight on something like Seroquel (and there are no contraindications). Also, living in Washington (or Florida) means no income taxes. Also, it your home is in Florida it is virtually exempt from being taken from lawsuits (there is a reason that OJ Simpson lived here for so long). Other states like Texas exempt virtually all income from garnishment (again another thing to think about if one is worried about being in a lawsuit some day). Perhaps, the best thing might be to own your home in Florida, work in Washington (tele), and "live" in Texas. Also, I refuse to wear a mask when I am out walking or just outside so California is pretty much off the table.
1. Our income and sales tax are high, but our property tax is pretty low. Our combined tax burden is high, but certainly not the highest.
2. I'm going to give a very simplistic example here.
Example 1 - Calif NP. $150K per year. Let's say 10% state income tax. So the net income is $140K per year.
Example 2 - Oklahoma NP - $100K per year. 5% state income tax. Net income $95K per year.
3. Cost of living is certainly a factor, but outside of San Diego, Los Angeles, and SF Bay Area, Calif is actually quite affordable in terms of housing. And the pay is actually higher outside of the coastal cities because the inland areas have a harder time attracting providers.
I heard an interesting radio bit from Dave Ramsay, king of thrifty living. He had a caller, a young man who had received a job offer in San Diego, making $150 K per year. The caller wondered if he could afford to live in San Diego. Ramsay laughed at him, saying of course he could! The average house cost was stiff affordable for his income level and since this appeared to be a great career opportunity, Ramsay told him he'd be a fool not to take it.
As someone pointed out earlier in this thread, that a old house in Seattle costs nearly 800K for a 2 bedroom, dated, shack... I bought that kind of house to live here. The house is 50 years old and has never touched, I bought it for a whopping $800k. I remember thinking that Dave Ramsey would probably kill me for buying a house like that, but the opportunities in the future persuaded me. Thank you for your comment, makes me feel a little bit better!
However, when it comes to NP's it is still good but has significant downsides. For example I manage many of my "simple" MDD patients with nothing other than SAM(e), multi vitamins (with extra B vitamins), Fish Oil and maybe something like Saint John's Wort (it it doesn't adversely interact with other medicines they might be taking. This is integrated with things like early morning sunlight, aerobic exercise, and yoga. Now in Florida I would be terminated in about a week at the majority of practices due to the conservative allopathic approach integrated with the strict supervision requirements.
This is what I particularly like about our state also.
Also, I refuse to wear a mask when I am out walking or just outside so California is pretty much off the table.
Best of luck to you, Inslee's new mandate is making this considerably more difficult. Even though the mandate excludes you when you are outside and can maintain social distancing, I got quite a few stares going without a mask yesterday. However I refuse to wear one when out an about, the only exception being in direct patient care.
Specializes in Psychiatric and Mental Health NP (PMHNP).
4 hours ago, myoglobin said:
Also, I refuse to wear a mask when I am out walking or just outside so California is pretty much off the table.
Well, I live in Sacramento and most people are not wearing masks when outdoors. I also hate wearing a mask, but if it's only for brief period while shopping, I can live with it.
I own my own practice ( telepsych) in the Seattle surburbs and charge $300 for new psych eval 60 minutes and $150 follow-ups 30 minutes. I am doing just fine. I initially started as cash pay which was great but then COVID hit and business has been slow. I think that is due to the fact that most people are holding on the cash unsure of what the economy future holds. I am now going through credentialing with most commercial insurances to grow faster. I work at my private gig Thursday, fri and every other sat.
I still have a full time job with a large healthcare organization here In Pierce working mon, tues, wed 12 hrs IP psych and make 96/hr with full benefits, student loan repayment, 30 days vaction, + 1 week CME time off with $2500/ yearly, all my licenses and DEA are paid for.
I think Seattle NP market is better. I am both Family and Psych NP. When I started almost 3 years ago as a FNP, I made $ 120 and got offers up till 145 with three years of experience. A friend of mine got a job offer around Federal Way full time brand new PMHNP at $160.00. I think that is pretty good considering we have no income tax.
I personally don't think our property taxes are that bad. Housing in WA is not as bad unless you want to live in King County or Snohomish county which is quite expensive. I bought a home in pierce county for a decent price at 460,000 5br/3 bth 290SqFt. My property tax is about $4,600/ yearly. I looked into property taxes in Sacremento CA for a $500,000 home, was averaging about 6,000/yr.
I love CA and not too crazy about WA due to the bipolar gloomy days but when I do the math, we are better off here in WA. Owning an NP business in WA is easier, faster and less restrictive. I am hoping CA will eventually move to Full practice within the next 5 years so that I can relocate but till then.
My point about not taking insurance is that I don't want to have to deal with the "hassles" of getting signed up again (I am already signed up with most Washington insurances, but only through my main two jobs one of which I am quitting). I assume getting signed up as "my own company" would be an entirely new process. On top of that I would have to actually bill insurance (I can barely get my charts done, order labs and deal with 24/7 texts and calls from my clients as it is). Thus, I figured if I had convenient hours, offered CAM interventions (which many others do not) and had "cheap" prices (by comparison $75.00 for a 30 minute visit and $150.00 for a 90 minute eval is kind of cheap). Then I should be able to earn "about" what I make now since I wouldn't be giving up 30% of my cut or paying a $500.00 service fee per month (for clerical and support services). Also, "in theory" I should have a bit more "security" since I don't have to worry about insurance audits or displeasing someone in "management" with what I say or do.
$55/hr in Las Vegas for 20+ yrs nursing experience? I live in Chicago, with 27 yrs experience and get $60.51/hr + 5 weeks vacation/yr and 10 sick days + health insurance for me and my family. I am retiring in 3 yrs with pension, but will still be young at 54, and was considering moving to Vegas as my daughter lives there. I'd still want to work part-time in a float pool or something if I move out there. Good to see it is pretty much the same pay as Chicago. What about Phoenix, Az.?
FullGlass, BSN, MSN, NP
2 Articles; 1,940 Posts
Most NPs are still better off in California.
1. Our income and sales tax are high, but our property tax is pretty low. Our combined tax burden is high, but certainly not the highest.
2. I'm going to give a very simplistic example here.
Example 1 - Calif NP. $150K per year. Let's say 10% state income tax. So the net income is $140K per year.
Example 2 - Oklahoma NP - $100K per year. 5% state income tax. Net income $95K per year.
3. Cost of living is certainly a factor, but outside of San Diego, Los Angeles, and SF Bay Area, Calif is actually quite affordable in terms of housing. And the pay is actually higher outside of the coastal cities because the inland areas have a harder time attracting providers.
I heard an interesting radio bit from Dave Ramsay, king of thrifty living. He had a caller, a young man who had received a job offer in San Diego, making $150 K per year. The caller wondered if he could afford to live in San Diego. Ramsay laughed at him, saying of course he could! The average house cost was stiff affordable for his income level and since this appeared to be a great career opportunity, Ramsay told him he'd be a fool not to take it.