NP Hates from Physicians?

[Myec]

Hi all,

The title says it all. Have you faced hates or disrespect from physicians (either attending or training) just because you are a NP? Because I did. Online. 

As a RN and a NP student, I have seen many great attending physicians who work collaboratively and respectively with NPs. That rosy perception completely changed once I joined Reddit medical communities. There are massive posts showing hates against NP. The two main areas of criticism come down to: 1. Taking NP's malpractice cases or individual's anecdotal examples to basically question competency of all NPs in the states (although I am curious as to malpractice cases in comparison with MDs), 2.  misunderstand and derogate the implication DNP (though it's an academic degree, not a clinical degree as MD, the physicians and trainee there seem to take it as NPs just trying to put a doctor title and lobbying to obtain an independent practice despite NP's allegedly inadequate competency. 

I am not here to say NPs are equally trained as MDs because they are certainly not. Also, I also feel NP education has definitely rooms for improvement (another area of discussion). 
Also, I acknowledge these people don't represent the majority medical societies so should take these views with a grain of salt. Nonetheless, I am unsure what to make out of the hates from these physicians (primarily in training) who will be our future coworkers other than trying to continuously learn and improve my competency and hopefully avoiding these toxic people in my future career if I have a choice. 

I would appreciate any insightful advice from current NPs in the field. Thank you! 

[FullGlass, BSN, MSN, NP]

22 hours ago, djmatte said:

I am curious where you are seeing salaries increasing though in this field, because I don’t see it. Reimbursement is dropping all the time. Just looking at my own clinic system (four clinics) I often feel mid levels are floating those salaries. We have 6 total docs (two own the practice who don’t see full loads and often come and go as they please) and everyone’s schedule is equally slotted. 15 min office visits and 30 min physicals.  None will see anyone outside those confines. And when they do their revenue reports, it’s clear their expenses are never met compared to lower paid staff who often exceed these measures.  These docs are getting paid at least twice the salary. But given MD reimbursement, the difference should only be 15% more. These docs aren’t seeing more patients and they’re billing for the same complexity as everyone else. 

You nailed it.  It's cost versus revenue.  No other business model would tolerate this.

In most professional careers, like law, consulting, accounting, etc., the costs and revenue generation of each professional are PUBLIC.  Amazing what that does.

As a practice manager in consulting (which I was), I would staff based on the economics.  I also provided consulting services to law firms, which do the same thing.  What you so succinctly explained is why these organizations have a pyramid structure and rely so heavily on more junior staff to do the bulk of the work.  Myoglobin is also correct in his approach to this.

Pay should be based on revenue generated, end of story.  There is no way practices should tolerate MDs making a lot more $ and not generating a lot more $ in revenue.  It makes no sense financially.

Let's say I owned my own PC practice.  I could hire 5 MDs, making $230K each, and (I'm just pulling this # out of thin air), generating $600,000 per year in revenue.  

MD staff

5 x 250K = 1,250,000 cost 

5 x 600K = 3,000,000 gross revenue

Proceeds to practice = 3,000,000 - 1,250,000 = $1,750,000

 

Let's say I looked at hiring only NPs for my clinic

5 x 150k (I'm being generous in pay) = 750,000

5 x (600k x .85 due to reimbursement) = 2,550,000

Proceeds to practice = 1,800,000

 

This is the brutal truth.  The very simplified example above looks even worse for the practice if the MDs do not carry a full load.  The NPs would end up subsidizing the MDs.  This is exactly why more and more outpatient practices are relying more on NPs and PAs.

In every other profession, higher pay would have to be justified by generating higher value and revenue, but this is not true in primary care.

This is why other professions have a pyramid structure.  You would have 1 MD for every 4 or 5 NPs, who would work on higher value cases and also provide consults to the NPs.  But of course, this would require some real change and innovation, which the medical establishment resists tooth and nail.  These are the same folks who resisted using the stethoscope for over 100 years.

And to my original point, making this data public to the practitioners would put a lot of pressure on MDs to step up their game, or else.  

This is why IPA for NPs is here to stay and will only increase, because it is cost-effective.

China made great strides in improving population health though using "barefoot doctors" after the Communist Revolution.  These were people who received some basic first aid and medical training, often only high school grads, who could handle common issues in villages, as well as provide basic health education.  It provided tremendous benefits.

 

 

 

 

[Tegridy]

I think a lot of the hate is towards MLP who think they can completely replace physicians. Not many people argue that some of the work physicians can do can be replaced by NP or pas, but all ? no, not in any single specialty can all. The organizations supporting NPs seem to portray this very aggressively so even those NPs who are good, know their limits, and do what is right get painted with a red brush.

 

I do not doubt that something like the above would happen at some point to some extent but job boards/markets just do not have that picture. Where I live there is a tremendous physician shortage yet a severe glut of PA and NPs. The hospital systems and large clinic systems could hire a zillion NP/PA quickly if they wanted to, but many go without jobs. Yet there are thousands of physician openings that go unfilled, that almost always are not filled by NP/PA. There will always be a mix of physicians and MLPs but I don't really see a ratio of 1:4 or 1:5 like anesthesia happening since there is always something happening in seeing patients, anesthesia is just mostly monitoring and has a much narrower scope, something that allows more supervising to occur. 

 

We can all care for the worried well, which is a lot of our business (not by our choice people are just anxious in general). We will see, its an interesting topic.

 

 

And a lot of patient's when paying the same amount for care no matter who they see will often pick a physician. Not always but if it were not the case primary care clinics would be not offering 300k plus to start in my area for a 4.5 workweek.

 

 

 

 

[Tegridy]

36 minutes ago, FullGlass said:

As a practice manager in consulting (which I was), I would staff based on the economics.  I also provided consulting services to law firms, which do the same thing.  What you so succinctly explained is why these organizations have a pyramid structure and rely so heavily on more junior staff to do the bulk of the work.  Myoglobin is also correct in his approach to this.

With the above statement it gives us the premise that many different business types are ran by those at the top who may not do much of the work. It's not only medicine. The part time docs sound like owners, and well, if a LPN owns the company then yeah they can make a lot and see no patients!.

 

 

Even in other fields often the mediocre employees make similar to the great ones. Unfortunately humans are human and likeness is more akin to more bucks than skill oftentimes. I am sure I am preaching to the choir on this though since you have been there and done the business things.

[djmatte, ADN, MSN, RN, NP]

29 minutes ago, FullGlass said:

You nailed it.  It's cost versus revenue.  No other business model would tolerate this.

In most professional careers, like law, consulting, accounting, etc., the costs and revenue generation of each professional are PUBLIC.  Amazing what that does.

As a practice manager in consulting (which I was), I would staff based on the economics.  I also provided consulting services to law firms, which do the same thing.  What you so succinctly explained is why these organizations have a pyramid structure and rely so heavily on more junior staff to do the bulk of the work.  Myoglobin is also correct in his approach to this.

Pay should be based on revenue generated, end of story.  There is no way practices should tolerate MDs making a lot more $ and not generating a lot more $ in revenue.  It makes no sense financially.

Let's say I owned my own PC practice.  I could hire 5 MDs, making $230K each, and (I'm just pulling this # out of thin air), generating $600,000 per year in revenue.  

MD staff

5 x 250K = 1,250,000 cost 

5 x 600K = 3,000,000 gross revenue

Proceeds to practice = 3,000,000 - 1,250,000 = $1,750,000

 

Let's say I looked at hiring only NPs for my clinic

5 x 150k (I'm being generous in pay) = 750,000

5 x (600k x .85 due to reimbursement) = 2,550,000

Proceeds to practice = 1,800,000

 

This is the brutal truth.  The very simplified example above looks even worse for the practice if the MDs do not carry a full load.  The NPs would end up subsidizing the MDs.  This is exactly why more and more outpatient practices are relying more on NPs and PAs.

In every other profession, higher pay would have to be justified by generating higher value and revenue, but this is not true in primary care.

This is why other professions have a pyramid structure.  You would have 1 MD for every 4 or 5 NPs, who would work on higher value cases and also provide consults to the NPs.  But of course, this would require some real change and innovation, which the medical establishment resists tooth and nail.  These are the same folks who resisted using the stethoscope for over 100 years.

And to my original point, making this data public to the practitioners would put a lot of pressure on MDs to step up their game, or else.  

This is why IPA for NPs is here to stay and will only increase, because it is cost-effective.

China made great strides in improving population health though using "barefoot doctors" after the Communist Revolution.  These were people who received some basic first aid and medical training, often only high school grads, who could handle common issues in villages, as well as provide basic health education.  It provided tremendous benefits.

 

 

 

 

Our information is somewhat public. They realease a quarterly report that showes everyone’s total expenses and billing. They just keep names blank. But it isn’t hard to tell who the high dollar people. The sad part is many have open charts that aren’t closed to the point that the charges are written off. 
 

On a separate note, I do find value in MD knowledge as I believe ours have greatly influenced my practice. So value should be somehow compensated.  The question is how many MDs do you need to fulfill this level of value. 

[Tegridy]

1 minute ago, djmatte said:

Our information is somewhat public. They realease a quarterly report that showes everyone’s total expenses and billing. They just keep names blank. But it isn’t hard to tell who the high dollar people. The sad part is many have open charts that aren’t closed to the point that the charges are written off. 
 

On a separate note, I do find value in MD knowledge as I believe ours have greatly influenced my practice. So value should be somehow compensated.  The question is how many MDs do you need to fulfill this level of value. 

The other option would be more of a team oriented approach. I know on most inpatient specialty services the NPs write the notes and do the obvious things the primary team should have/maybe forget since they have every other organ system to worry about. Or just looked in their clinic record that only they have access to. Then the attending rounds quickly on everyone with the NP and does what he or she sees fit and changes things if needed.

[djmatte, ADN, MSN, RN, NP]

7 minutes ago, Tegridy said:

The other option would be more of a team oriented approach. I know on most inpatient specialty services the NPs write the notes and do the obvious things the primary team should have/maybe forget since they have every other organ system to worry about. Or just looked in their clinic record that only they have access to. Then the attending rounds quickly on everyone with the NP and does what he or she sees fit and changes things if needed.

Probably wouldn’t be a fit in primary care. As it stands everyone across the board are billing majority 214 patients. The same acuity is seen by the same clinician at every level. 25-30 patients a day. So it would be something of an impossibility to screen in advance and a proverbial excrement show to lump a bunch of high acuity patients on only a few people. There’s no opportunity to do “rounds” in a clinic setting where schedules and patient visit types ebb and flow. And really there’s no excuse for an md to have open charts 6 months or later than the patient was seen... pushing into hundreds of visits which are written off when mid levels take their work home because they get worried about two days out.  But that’s a management issue more than anything. 
 

An option might be one md per clinic who acts as a more supervisor with a reduced load who mentors and cultivates their own limited but complicated population with a range of mid levels to handle the rest. But that would require an entire system overhaul this practice will never go for. 

[Tegridy]

24 minutes ago, djmatte said:

Probably wouldn’t be a fit in primary care. As it stands everyone across the board are billing majority 214 patients. The same acuity is seen by the same clinician at every level. 25-30 patients a day. So it would be something of an impossibility to screen in advance and a proverbial excrement show to lump a bunch of high acuity patients on only a few people. There’s no opportunity to do “rounds” in a clinic setting where schedules and patient visit types ebb and flow. And really there’s no excuse for an md to have open charts 6 months or later than the patient was seen... pushing into hundreds of visits which are written off when mid levels take their work home because they get worried about two days out.  But that’s a management issue more than anything. 
 

An option might be one md per clinic who acts as a more supervisor with a reduced load who mentors and cultivates their own limited but complicated population with a range of mid levels to handle the rest. But that would require an entire system overhaul this practice will never go for. 

it’s harder in primary care oftentimes. I know the specialty clinics use NP more for simple follow ups on the less complex stuff but primary care is more difficulty as you say to filter those out

[myoglobin, ASN, BSN, MSN]

1 hour ago, Tegridy said:

it’s harder in primary care oftentimes. I know the specialty clinics use NP more for simple follow ups on the less complex stuff but primary care is more difficulty as you say to filter those out

The clinic where I go for care (and take my son in Florida no less) is staffed only by NP's and PA's.  They have a supervising MD who is seldom on site (I have never seen) and they see three patients per hour on average (it is a prompt care clinic). I pay $150.00 for a standard visit. However, a PA there told me he is earning around 110K per year.  They always have a 1 to 4 hour wait to be seen.  Thus, I postulate that the PA is generating at least $300  per hour, but is earning closer to $50.00 per hour. In what world would he not make much more income on split system say at 70%? Yesterday, I saw 18 patients with an average patient payout of $150.00 per patient or about $2,700 (granted it was a better than average day since I had only one intake and we are talking mental health).  However, if I did that everyday I would gross $518,400 per year (and there are people at my company who come close to that as NP's making 70%).  Please tell me why a "percentage" system isn't better in almost every case?

[djmatte, ADN, MSN, RN, NP]

33 minutes ago, myoglobin said:

The clinic where I go for care (and take my son in Florida no less) is staffed only by NP's and PA's.  They have a supervising MD who is seldom on site (I have never seen) and they see three patients per hour on average (it is a prompt care clinic). I pay $150.00 for a standard visit. However, a PA there told me he is earning around 110K per year.  They always have a 1 to 4 hour wait to be seen.  Thus, I postulate that the PA is generating at least $300  per hour, but is earning closer to $50.00 per hour. In what world would he not make much more income on split system say at 70%? Yesterday, I saw 18 patients with an average patient payout of $150.00 per patient or about $2,700 (granted it was a better than average day since I had only one intake and we are talking mental health).  However, if I did that everyday I would gross $518,400 per year (and there are people at my company who come close to that as NP's making 70%).  Please tell me why a "percentage" system isn't better in almost every case?

Comes down to the individual comfort level. Some people feel better about a hard salary with benefits and maybe bonuses based on productivity. Some days I walk in to 10 no shows. And for Medicaid patients you can’t charge them for these instances. So while I know my broader productivity exceeds my costs, many don’t want to live their paycheck based on the hard numbers. Even if it puts them under their value.  Those people do need to be more vigorous about their salary negotiations (many aren’t) if they recognize what they’re bringing vs what they’re being paid. 

[myoglobin, ASN, BSN, MSN]

4 minutes ago, djmatte said:

Comes down to the individual comfort level. Some people feel better about a hard salary with benefits and maybe bonuses based on productivity. Some days I walk in to 10 no shows. And for Medicaid patients you can’t charge them for these instances. So while I know my broader productivity exceeds my costs, many don’t want to live their paycheck based on the hard numbers. Even if it puts them under their value.  Those people do need to be more vigorous about their salary negotiations (many aren’t) if they recognize what they’re bringing vs what they’re being paid. 

To even have relevant discussions you would need good data on your revenues along with expenses.  Also, I get it if you are in a clinic that is primarily Medicaid, but most places are a "mix" with Medicaid merely being a part.  I simply do not believe that most NP's wouldn't earn at least 200k in a clinic structure that paid 60-70% of revenues.  

To even have relevant discussions you would need good data on your revenues along with expenses.  Also, I get it if you are in a clinic that is primarily Medicaid, but most places are a "mix" with Medicaid merely being a part.  I simply do not believe that most NP's wouldn't earn at least 200k in a clinic structure that paid 60-70% of revenues.  By the way you are always on commission at least on the down side since I assure you that even if you have a 100K salary if your productivity were to fall below that number for very long you would be looking for another job.  It's just that your "up" side is limited.

[djmatte, ADN, MSN, RN, NP]

Just now, myoglobin said:

To even have relevant discussions you would need good data on your revenues along with expenses.  Also, I get it if you are in a clinic that is primarily Medicaid, but most places are a "mix" with Medicaid merely being a part.  I simply do not believe that most NP's wouldn't earn at least 200k in a clinic structure that paid 60-70% of revenues.  

We’re a broad mix. And we don’t pursue penalties again the others either.  But Medicaid can easily account for a quarter to half my load. When I have a family of five well child who no show, that’s 2.5 hours of no pay. 
 

but when you’re talking those splits, you’re talking no benefits, no 401/retirement plan. Creature comfort’s many clinicians have grown accustomed to. So for many it wouldn’t sell. 

[myoglobin, ASN, BSN, MSN]

23 minutes ago, djmatte said:

We’re a broad mix. And we don’t pursue penalties again the others either.  But Medicaid can easily account for a quarter to half my load. When I have a family of five well child who no show, that’s 2.5 hours of no pay. 
 

but when you’re talking those splits, you’re talking no benefits, no 401/retirement plan. Creature comfort’s many clinicians have grown accustomed to. So for many it wouldn’t sell. 

Those "creature" comforts might be worth 30K to 50K so if the difference is 100K vs even 150k I say you've got a point. But once you are North of 200K you can easily "purchase" all of those "creature comforts" yourself, and of equal or better quality. Let's break it down:

1. Employer portion of SSI and Medicare around 7%.

2. Employer paid portion of health insurance maybe 10K at best.

3. Employer paid part of a 401K maybe 10K if you max it out.

4. Paid time off. Maybe 5-10K each year. .

5. Educational benefits 2K

At best we are in the 35 to 50K value range here.