I've been an NP for a while, and I am happy and proud to be one. I am well aware of both our shortcomings and our successes. I think we fill a need in the world of healthcare, and "going to see my NP" has become a normal phrase in American households.
For all of our successes, we seem to have a problem with consistently selling ourselves short when it comes to compensation. I have been reaching out to colleagues and previous students, and I have also been serving as a mentor for some new NP graduates looking for advice. As they navigate positions, one common theme is they do not know how much they are worth, and do not understand that as a provider they are revenue producers! We should be paid as such!
Case in point: last week I had a new graduate FNP telling me about a job in a specialty office she intended to accept. She told me she was satisfied with the salary and benefits and shared them with me. It turned out to be a salaried position at $96K annually working 8 AM to 5 PM five days a week. Vacation was 2 weeks paid going up to 3 weeks after FIVE years. It included all the usual benefits but there was no 401K match and no CME.
Sometimes I feel like nurse practitioners are not being taught about healthcare economics at all. Maybe instead of 4-5 classes on research and "NP roles" we should be teaching a dedicated course on billing and reimbursement? I see NP after NP working for peanuts while the practice that employs them is making hundreds of dollars per hour off of their work. The long-term effect, of course, is that all NP salaries will start to flatten out. Those that do the research and demand a salary that reflects what they bring to the practice will be laughed out the door while those who do not know their worth will end up taking their place.
Does anyone else notice this in the NP world? What can we do to bring awareness to it? Let's Discuss! ?
I am in the DNP program currently working on my AGNP. I politely disagree with you. I think it depends on where you reside. The rural area in which I live makes it hard to get to my state university 4 hours away for classes, however, in my town there is such a demand for primary and specialty care that people are waiting up to 8 months to see a specialty and up to 6 months to see primary care, if they are lucky enough to get an appointment and if that particular practitioner is accepting patients.
I agree with you, I live in a rural farm area where Universities are hours away. There is a high demand for Nurse Practitioners in this area—there is no over-supply issue here. In fact, there are great opportunities for Nurse Practitioners to travel to the smaller towns to provide care. And for PMHNPs there is a booming business in telehealth.
I'm curious, how do we fix those things? I have actually written letters in the past to the credentialing boards asking why they continue to certify low performing programs that graduate thousands of NPs annually with almost no oversight. I explain how it hurts the profession both by causing a massive oversupply and by graduating subpar NPs that perform poorly and hurts the reputation of nurse practitioners for colleagues and patients. I have never even received a reply.
I do agree with you though. Part of the problem is that nurse practitioners who find themselves unable to find a job become desperate and accept jobs that are insulting. 1-2 weeks of vacation, pay that works out to 5-10% of what they bring in to the practice, etc.
It depends on where you live in this country. We do not have a glut of Nurse Practitioners here. NPs are in great demand.
One of the great things about a nursing career is flexibility. NP is NOT the only path for RN advancement.
Southern California, especially San Diego County, is a very tough job market for ALL healthcare professionals, including MDs. San Diego County tends to pay less than other parts of California, as well, and that goes for MDs, too. I think the reason is that it is a beautiful place to live, so a lot of people want to live there. In addition, due to the heavy military presence, there are a lot of military spouses that are healthcare professionals. Finally, a lot of military folks retire there, and many are in their late 30s or early 40s, and that includes a lot of healthcare professionals who are ex-military. This leads to excess supply versus demand. That means jobs are harder to find and pay less.
It is easier to find a job in the LA area than in San Diego County.
I previously suggested this, but here is what you can consider:
1. Moving to an area with a lower cost of living and that likely will have higher pay.
2. Finding a job within a 4 or 5 hour drive that allows you to do 4 ten-hour days or 3 twelves, then rent a room where you work and commute home on weekends for 1-2 years.
3. Look for a job within a 1.5 hour drive of where you live and do a long commute for 1-2 years. In SoCal, a lot of people have commutes this long or longer.
There may have to be some short-term pain in order to obtain long-term gain.
The past year, the job market for NPs has generally sucked due to COVID. Many RNs, NPs, MDs, have been laid off, but the job market is picking back up again as life returns to normal.
You may also wish to research Health Professional Shortage Areas (HPSAs). Find HPSAs within your commuting area and focus job search there.
Don't just look at job listings. Make a list of all the possible employers in your area and apply even if they don't have a job listing. Federally Qualified Health Centers (FQHCs) are a good option.
HRSA has virtual job fairs. Google this. They occur about every 3 months and have employers from all 50 states. Attend and apply to any in your area, whether or not they have active openings.
Finally, due to COVID, there are more telehealth providers for primary care. Telehealth is well-suited to many patients for certain conditions. This means an NP can work remotely. Research such companies and apply to them. You could obtain an NP license in FPA states in order to make it easier to work for such companies.
The harsh reality is that it may be necessary to make some sacrifice for the first NP job. Once you have 1-2 years of experience, it will be MUCH easier to get a job.
I think one aspect of the problem is lack of knowledge about similar positions and what they make. For primary care and other established positions it may be a bit easier to find salary data but for specialty it's difficult. Being clear with your employer about the practice's profit and costs is important. You should know this info and as nurses we often don't ask these questions. I am going back and forth about requesting a raise and additional benefits currently and as an NP in a sub specialty it is frustrating to find info on comparable jobs and salaries. The info from national surveys is not applicable and varies widely.
I think one aspect of the problem is lack of knowledge about similar positions and what they make. For primary care and other established positions it may be a bit easier to find salary data but for specialty it's difficult. Being clear with your employer about the practice's profit and costs is important. You should know this info and as nurses we often don't ask these questions. I am going back and forth about requesting a raise and additional benefits currently and as an NP in a sub specialty it is frustrating to find info on comparable jobs and salaries. The info from national surveys is not applicable and varies widely.
It can’t be that different than primary care. At the end of the day, you are billing for a range of office visits and or procedures. Understanding what you bill and when is the first step. The company should be able to give you information on what they charge the insurances and what is actually paid out. Past that you sort out a reasonable pay based on a base and benefits.
Practices often know what you’re overhead is. They don’t always disclose how that breaks down though. Another Avenue is to sort out your overhead and get bonuses based on exceeding that. That way you don’t have to worry about asking for a raise because your productivity will get you more money.
I agree with the above, and also think concrete guidelines would be helpful for those looking for jobs. Some ideas:
Ask what the average provider brings in to the practice in terms of revenue. You should be getting a decent percentage of that. Time and time again I see NPs in lucrative specialties who being in 350-500K and are paid 95K or less annually. You deserve a piece of the pie!!
Make sure you get at least 4 weeks vacation. You'll need it!
Don't accept 40+ hour work weeks. I've seen positions that advertise 8AM to 6PM five days a week. That's burnout! If you work those hours, ask for 4 days a week for full-time.
Always ask for paid admin time! It can be a half day per week or an hour at the end of every day but you need time to make calls and finish charts, and otherwise you'll be doing it for free at home.
For a full-time, 40 hour work week the average NP should make no less than $120K annually. Shoot for that as a minimum.
This right here is excellent information!
As a new grad, I would have loved a class on healthcare economics. With programs ever changing, perhaps the next generation will have that as a mandatory class. It is one thing to log your cases in with ICD and CPT, but it’s also another to see what the patient generates for the practice.
We learned some of the maneuvers and tests like Lachman, but there are a boatload and a new grad or primary care NP is generally not expected to know all of them. My mentor on my first job (primary care) was an MD who did an ortho residency at Mayo Clinic and he said there was no need for all primary care providers to know all of these. The reason is that if there is joint pain, you do a basic PE and then send for appropriate imaging. If there is a problem, you are likely going to send them to ortho and/or PT anyway, and they are going to perform advanced ortho assessment. At least that's the way we did it.
The point of many of these tests is that they narrow down your differential and point you to the most appropriate imaging to be performing. They're really part of a more comprehensive assessment of the patient's chief complaint. That's why I find them important, but you're right, most of the primary care NP preceptors I had were unfamiliar with them. I have a particular interest in orthopedics, so I took the time to learn them and the nuances of orthopedic assessment, diagnostics, and management. I might even go for the post-master's certification in orthopedics. Part of our role is also knowing when not to image, such as utilizing the Ottowa ankle rules, assessing for ankle sprains vs ankle fracture or distal fibular fracture.
This is a fascinating conversation. I'm still in school-- is there a good place to look to learn the economics part? I feel very confused about billing, overhead, and RVUs...
This is a fascinating conversation. I'm still in school-- is there a good place to look to learn the economics part? I feel very confused about billing, overhead, and RVUs...
Many of these things will vary by location. But having these questions at an interview may impress your potential employer. As a provider, you are the revenue generator for your clinic presuming you are working in private practice. That means the rent, utilities, cost of staff, benefits, etc are all derived from the number of patients you see and what you bill for. Added up and typically divided by the provider total gives your overhead. Some providers may have higher overhead depending on their individual needs (for instance use of a scribe).
RVUs are a simplistic method of determining payment based on performance. Many clinics might assign a specific dollar number to this and give bonuses based on meeting or exceeding those numbers. These are often quarterly but can happen more or less frequently.
Billing varies by what you are seeing a patient for and account for both the complexity of the case as well as the range of tasks that occur during that visit. The billing codes with a typical office visit are assigned specific payment schedules by CMS and insurance companies. On top of that, a range of procedure codes can add to the billing and can also improve RVU generation if that’s a system the clinic utilizes.
Like I suggested earlier, drop questions like this on an employer and they will recognize your looking at far more than your capacity to secure a job. It shows you have interest in you’re abilities and feasibility to bring more money into the practice.
The quoted position was 45 hours, as it was 8AM to 5PM 5 days per week. So again, 41$.
And this attitude is exactly why so many nurse practitioners accept low paying jobs. They come to sites like this for support and instead of saying "wow, that's a horrible salary they are taking advantage of you!" and advocating for our fellow providers, you have people who instead go into the "Eat the young" mode and say that a new grad is in "no position" to ask for an ethical wage and should just eat whatever scraps they are offered. I completely disagree. We are providers, and a "new grad" is not going to bill any less per appt than an experienced graduate will. If the concern is seeing fewer patients per hour, then the new graduate NP can ask for a base salary +bonus based on RVUs or # of patients seen per quarter. This will allow the NP to increase salary as they become proficient. These days of paying an NP $40 an hour to see 5-6 patients and billing out $300-400 worth of services per hour on behalf of the practice need to end.
PsychNurse24, BSN, RN
143 Posts
I agree with you, I live in a rural farm area where Universities are hours away. There is a high demand for Nurse Practitioners in this area—there is no over-supply issue here. In fact, there are great opportunities for Nurse Practitioners to travel to the smaller towns to provide care. And for PMHNPs there is a booming business in telehealth.