Members are discussing the salaries and job opportunities for nurse practitioners in different specialties, such as primary care and psychiatric mental health. Some members are comparing the pay differences between different NP specialties, while others are sharing their personal experiences and reasons for choosing a specific specialty. Overall, the discussion revolves around the factors influencing NP career choices, including salary, job satisfaction, and personal interest in a particular field.
Transparency is important so we can negotiate. As a new grad nurse practitioner I accepted a ridiculously low paying position and I assumed that was the pay in the new city I move to. I have grown over the past couple years and I understand I was taken advantage of. I hope that this doesn't happen to others. Therefore, I believe it is critical we know what other nurse practitioners are being compensated so we are able to negotiate our salary and benefits packages.
I'm an FNP-C in Houston area working in Surgery (first assist, preop, and follow up post op care) Salary is 110k (negotiating to 115k), 3 weeks pto, 9 paid holidays, 1500 CME/yr, paid DEA, malpractice, 401k without match, 4 day work week (40-50hrs), on-call practically all the time (but only get calls on surgery days 2-3days/week). Overall I'm happy with the work I do.
I truly appreciate you for starting this important discussion. You have made me do a lot of thinking and research.
A lot of NPs are undoubtedly underpaid. At least in the Western U.S., I am seeing pay going up across the board, due the shortage of providers, including in primary care. In fact, I am seeing primary care compensation going up the fastest, as there is a dire shortage of PCPs.
What is interesting, is that the same is not true of mental health. California has a terrible shortage of mental health care providers. PMHNP pay used to be significantly higher than for PCPs, but that is no longer the case. One would think that due to supply and demand, mental health care pay would be increasing a lot, but it isn't. The only way for PMHNPs to make a lot more money is to essentially open their own practice by signing up for platforms will provide the billing services, along with some referrals.
I also remembered that PMHNPs and psychiatrists may be subsidizing the pay of talk therapists. The talk therapy shortage is far worse than for med mgt, at least in California. My experience has been working in FQHCs and practices that provide both med mgt and talk therapy. The problem is that insurance companies pay really poorly for talk therapy, so most talk therapists have private practices that are cash pay only. In organizations like mine, the med mgt providers are providing subsidies to increase talk therapy pay so the organization can attract therapists to work for them. I'm OK with some of this, as I have a personal commitment to working with underserved populations. Those populations can't afford to pay cash for talk therapy or any other health services. In the long run, PMHNPs and psychiatrists should be advocating for increased insurance reimbursement for talk therapists.
As a management consulting executive, I ran my own practice, and our target profit margin was around 30-40%, for gross margin. That's before expenses, which were considerable. A health organization also needs to have some savings for unexpected events and downturns.
Personally, I think that once NPs in California have FPA, we should be getting insurance reimbursements that are equal to MDs' if the NP is truly practicing independently and does not require MD supervision. I believe this is the case in Oregon.
At this point in time, I am happy where I am. I just got a raise to $100 per hour with 18 days vacation, 5 days sick time, and 5 days CME time. That's almost 30 days per year paid time off total. I don't need to worry about getting patients or billing. In addition, my current employer is very flexible, so I can work as little as 8 hours per week or all the way up to 40 hours per week - it is up to me. That flexibility is very important to me right now. I have gone through the wringer personally in the past several years and just don't have the mental and emotional energy to do what would be needed to make a boatload of money by going a more independent practice route via 1099. I've been practicing solely in mental health for about 3 years now and want to focus on building my expertise as a PMHNP. In a few years, I plan to open my own practice. Finally, I won a HRSA scholarship and my current employer qualifies to fulfill the public service obligation.
So, I suggest PMHNPs consider what things are most important to them. For example, a job like mine would be ideal for a parent who wants more time with their child(ren), or someone who is pursuing further education, so they can work part-time and still get benefits.. It would not be the best choice for someone who wants to max out their income. PMHNPs that won a HRSA scholarship or who want to pursue state or federal student loan repayment will also have employment constraints for a few years.
Again, MentalKlarity, my thanks to you.
You're very welcome! I agree, there is more to the picture than pay - flexibility and work-life balance are so important! In my case, I made it clear to my employer I needed generous paid and unpaid vacation as I want to have vacation time - I actually took a slight paycut in exchange for some more flexibility with time off so I could enjoy my life and not just work.
That said, agree that many NPs simply do not know what they bring in and that is a big issue. I can tell you that the clinic I work in has a fairly low overhead (we have one MA and one front office person), the building rent is cheap, and there are numerous providers. I actually requested to review my collections with my employer and saw that on average the insurance companies were reimbursing at nearly $250+ per patient (2 per hour, so bringing in sometimes $500 an hour depending on their insurance provider) that I was seeing. I requested either an hourly rate that gave me a substantial portion of that, accounting for people who don't pay or don't show or have inferior insurance, or to give me a fair split of what I bring in. We settled on a split, which is at 75%. My employer is still making a profit off of me, and I am happy with that because everyone can win and benefit in the end. There is absolutely no reason why some nurse practitioners are out there billing for $300K-$500K or more depending on specialty and getting $100K in salary.
Ask yourself - why would clinics hire more nurse practitioners over physicians? Which brings more prestige, etc? It's because the physicians are asking for a salary that is closer to what they bringing in. Paying a physician who brings in $500K a salary of $375K is a LOT less attractive to a clinic than hiring an NP who bills for $400K but is happy at $120K salary. They can literally make double on the NP, because NPs do not know their worth like physicians do.
Specializes in Psychiatric and Mental Health NP (PMHNP).
MentalKlarity said:
You're very welcome! I agree, there is more to the picture than pay - flexibility and work-life balance are so important! In my case, I made it clear to my employer I needed generous paid and unpaid vacation as I want to have vacation time - I actually took a slight paycut in exchange for some more flexibility with time off so I could enjoy my life and not just work.
That said, agree that many NPs simply do not know what they bring in and that is a big issue. I can tell you that the clinic I work in has a fairly low overhead (we have one MA and one front office person), the building rent is cheap, and there are numerous providers. I actually requested to review my collections with my employer and saw that on average the insurance companies were reimbursing at nearly $250+ per patient (2 per hour, so bringing in sometimes $500 an hour depending on their insurance provider) that I was seeing. I requested either an hourly rate that gave me a substantial portion of that, accounting for people who don't pay or don't show or have inferior insurance, or to give me a fair split of what I bring in. We settled on a split, which is at 75%. My employer is still making a profit off of me, and I am happy with that because everyone can win and benefit in the end. There is absolutely no reason why some nurse practitioners are out there billing for $300K-$500K or more depending on specialty and getting $100K in salary.
Ask yourself - why would clinics hire more nurse practitioners over physicians? Which brings more prestige, etc? It's because the physicians are asking for a salary that is closer to what they bringing in. Paying a physician who brings in $500K a salary of $375K is a LOT less attractive to a clinic than hiring an NP who bills for $400K but is happy at $120K salary. They can literally make double on the NP, because NPs do not know their worth like physicians do.
Good points. However, the places I've worked and work now are always happy to hire MDs or DOs. They've never turned down an MD they liked who wanted a job there, assuming salary was in line, etc.
I'd be interested in trying your negotiating tactic once I have 5 years PMHNP experience.
Frankly, I've had a lot of heartburn due to subpar PMHNPs. They simply are not worth even $100K per year, IMHO. They cause a lot of patient churn and anger, trouble for other providers, and open the practice up to massive liability issues.
I'm very frustrated that the NP profession does not police itself and does little to maintain education standards. I'm sick of these crappy schools, and I'm not just talking about for-profit schools, that will accept anyone with a pulse and evidently fail to teach even the basics of good clinical practice and professional behavior and ethics. *sigh* I'm seeing a lot of people decide they want to become a PMHNP because they think it is "easy" and they will make a lot more money. These schools do not even require the ability to speak and write in understandable English, which can be very dangerous, as it leads to patient confusion and frustration.
So, yes, I agree a good PMHNP with at some solid experience under their belt should be making a better percentage of their billing.
You're very welcome! I agree, there is more to the picture than pay - flexibility and work-life balance are so important! In my case, I made it clear to my employer I needed generous paid and unpaid vacation as I want to have vacation time - I actually took a slight paycut in exchange for some more flexibility with time off so I could enjoy my life and not just work.
That said, agree that many NPs simply do not know what they bring in and that is a big issue. I can tell you that the clinic I work in has a fairly low overhead (we have one MA and one front office person), the building rent is cheap, and there are numerous providers. I actually requested to review my collections with my employer and saw that on average the insurance companies were reimbursing at nearly $250+ per patient (2 per hour, so bringing in sometimes $500 an hour depending on their insurance provider) that I was seeing. I requested either an hourly rate that gave me a substantial portion of that, accounting for people who don't pay or don't show or have inferior insurance, or to give me a fair split of what I bring in. We settled on a split, which is at 75%. My employer is still making a profit off of me, and I am happy with that because everyone can win and benefit in the end. There is absolutely no reason why some nurse practitioners are out there billing for $300K-$500K or more depending on specialty and getting $100K in salary.
Ask yourself - why would clinics hire more nurse practitioners over physicians? Which brings more prestige, etc? It's because the physicians are asking for a salary that is closer to what they bringing in. Paying a physician who brings in $500K a salary of $375K is a LOT less attractive to a clinic than hiring an NP who bills for $400K but is happy at $120K salary. They can literally make double on the NP, because NPs do not know their worth like physicians do.
Arguably many clinics are utilizing NPs to subsidize the salaries of physicians. They can justify paying a physician closer to or even above what they bring in on the backs of much lower paid NPs who are paid a third or less of ever they actually see. With there technically being a physician shortage, this is how physicians are lured in and kept. We're subsidizing their salary and having that token doctor on board gives the clinic a selling point. .
Specializes in Psychiatric and Mental Health NP (PMHNP).
MentalKlarity said:
Paying a physician who brings in $500K a salary of $375K is a LOT less attractive to a clinic than hiring an NP who bills for $400K but is happy at $120K salary. They can literally make double on the NP, because NPs do not know their worth like physicians do.
I'm not sure where these numbers are coming from. I guess it depends on location. In California, a FT PMHNP is going to make $150K to $220K per year, in general. There are some outliers below and above, of course. It is extremely rare now for a FT PMHNP to make less than $160K per year here, and that is for someone with little experience.
In California, a FT psychiatrist MD (who is an employee) is going to make $250K to $400K per year. Again, there are some outliers. Most of the psychiatrist jobs that are posted are in the $250K to $350K range.
Psychiatrists here are not having any trouble finding jobs because we have such a shortage of mental health care providers. Psychiatry is still not the most desirable specialty for med students (although that is improving) and the majority of psychiatrists are older and will be retiring over the next 10-20 years without enough MD replacements.
My experience in a large mental health practice is that most PMHNPs are kind of a pain and require a lot of supervision. Sorry, but that is the brutal truth. So not only are they not billing as much, they require a lot more hand-holding. They have also lost a lot of patients from the practice due to poor care. Not only do they not follow clinical guidelines, they are also completely lacking on common sense. Frankly, most of them are lucky to be making as much money as they are.
I'm not sure where these numbers are coming from. I guess it depends on location. In California, a FT PMHNP is going to make $150K to $220K per year, in general. There are some outliers below and above, of course. It is extremely rare now for a FT PMHNP to make less than $160K per year here, and that is for someone with little experience.
In California, a FT psychiatrist MD (who is an employee) is going to make $250K to $400K per year. Again, there are some outliers. Most of the psychiatrist jobs that are posted are in the $250K to $350K range.
Psychiatrists here are not having any trouble finding jobs because we have such a shortage of mental health care providers. Psychiatry is still not the most desirable specialty for med students (although that is improving) and the majority of psychiatrists are older and will be retiring over the next 10-20 years without enough MD replacements.
My experience in a large mental health practice is that most PMHNPs are kind of a pain and require a lot of supervision. Sorry, but that is the brutal truth. So not only are they not billing as much, they require a lot more hand-holding. They have also lost a lot of patients from the practice due to poor care. Not only do they not follow clinical guidelines, they are also completely lacking on common sense. Frankly, most of them are lucky to be making as much money as they are.
Well that I agree with, and the unfortunate truth is that within the next 10-20 years nurse practitioners will likely make less than they do now as lack of regulation by the nursing organizations has allowed poor quality programs to flourish that lack any sort of oversight and admit anyone with a pulse. The result is a huge cohort of nurse practitioners who are borderline ignorant and incapable of managing complex patients and overtime they will cause the public and other professionals to sour on nurse practitioners and "demand" to see a psychiatrist. I already see ads at local mental health clinics that say patients will "only ever see a psychiatrist" because of public distaste. The nursing organizations are chasing short term gain (more money from more students going to school, taking board exams, paying dues) over the long game plan and will eventually see it blow up in their faces. Quantity over quality is a losing game.
Specializes in Psychiatric and Mental Health NP (PMHNP).
djmatte said:
Arguably many clinics are utilizing NPs to subsidize the salaries of physicians. They can justify paying a physician closer to or even above what they bring in on the backs of much lower paid NPs who are paid a third or less of ever they actually see. With there technically being a physician shortage, this is how physicians are lured in and kept. We're subsidizing their salary and having that token doctor on board gives the clinic a selling point. .
I do not agree that NPs are subsidizing MD pay. Where are you getting your information regarding this?
The brutal truth is that psychiatrists should be making quite a bit more than PMHNPs. Medical education and training is far superior to that of most PMHNPs. MDs have 4 years of med school, plus internship and residency, maybe a fellowship. Internship + residency = 4 years. Many also have a 1-2 year fellowship on top of that. Given the low quality of all-too-many PMHNPs now, I do not begrudge MDs for making more money.
Given that, the pay difference is reasonable. In California, PMHNP pay range is generally $150K to $200K, and they must practice under MD supervision for now. Psychiatrist pay (for an employee) seems to be running $250K to $400K in general. PMHNPs can make a lot more money as 1099 contractors, and many do. Some will be able to practice independently within a few years, which should also increase their potential earnings as they could open up their own practice. At present, someone who requires supervision just isn't going to be paid as much as someone who can practice independently.
I also think some people here are underestimating the overhead cost of running a practice and having employees.
Finally, owners of practices are entitled to profit. Frankly, in a capitalist economy, as much as they can get! It takes a lot of work to build a practice, and all that legwork is generally not compensated at the time. So, the smart practice owner will pay employees as little as they can and still get good people! If they can't attract and keep good people, then they increase the pay. That is how a market economy works. I know people who started a practice or business, and it is very difficult. Most make very little money for the first 2-3 years. Dealing with all the admin trivia and stuff when having employees is a big headache and time-consuming, as well as costly.
Should PMHNPs be smarter and tougher in negotiating pay? Yes. However, they also have to be realistic.
And psychiatrists are not always replaced by PMHNPs. I've had psychiatrists complain to me they were replaced by younger psychiatrists that are cheaper! At least in my experience, practices are always happy to hire an MD if the practice needs another provider.
Finally, at least in California, which is still restricted practice, an MD can't "supervise" an infinite number of NPs. There is a limit. So a practice can't expand by only hiring NPs. I think an MD here can supervise 10-12 NPs (but I didn't check that for sure).
I do not agree that NPs are subsidizing MD pay. Where are you getting your information regarding this?
The brutal truth is that psychiatrists should be making quite a bit more than PMHNPs. Medical education and training is far superior to that of most PMHNPs. MDs have 4 years of med school, plus internship and residency, maybe a fellowship. Internship + residency = 4 years. Many also have a 1-2 year fellowship on top of that. Given the low quality of all-too-many PMHNPs now, I do not begrudge MDs for making more money.
Given that, the pay difference is reasonable. In California, PMHNP pay range is generally $150K to $200K, and they must practice under MD supervision for now. Psychiatrist pay (for an employee) seems to be running $250K to $400K in general. PMHNPs can make a lot more money as 1099 contractors, and many do. Some will be able to practice independently within a few years, which should also increase their potential earnings as they could open up their own practice. At present, someone who requires supervision just isn't going to be paid as much as someone who can practice independently.
I also think some people here are underestimating the overhead cost of running a practice and having employees.
Finally, owners of practices are entitled to profit. Frankly, in a capitalist economy, as much as they can get! It takes a lot of work to build a practice, and all that legwork is generally not compensated at the time. So, the smart practice owner will pay employees as little as they can and still get good people! If they can't attract and keep good people, then they increase the pay. That is how a market economy works. I know people who started a practice or business, and it is very difficult. Most make very little money for the first 2-3 years. Dealing with all the admin trivia and stuff when having employees is a big headache and time-consuming, as well as costly.
Should PMHNPs be smarter and tougher in negotiating pay? Yes. However, they also have to be realistic.
And psychiatrists are not always replaced by PMHNPs. I've had psychiatrists complain to me they were replaced by younger psychiatrists that are cheaper! At least in my experience, practices are always happy to hire an MD if the practice needs another provider.
Finally, at least in California, which is still restricted practice, an MD can't "supervise" an infinite number of NPs. There is a limit. So a practice can't expand by only hiring NPs. I think an MD here can supervise 10-12 NPs (but I didn't check that for sure).
Imo you should eat what you kill. We literally bill for 85% off what an MD bills for. That's where the value of their advanced degree should lie. Midlevels make a fraction of what they bring in while I've seen MDs break even or come well under what they actually make. Having a swarm of mid levels around 1-2 doctors in a clinic can bring in higher salaries which are more attractive to MDs who are harder to get in the door. It's economics, but not equity of value. Take your example. 10-12 mid levels per MD practically pays the salary for 3-4 doctors. And the clinic still makes money hand over fist even if that doctors sole task is to keep them undereducated mid levels in line. If an MD makes 300k a year, your mid level of equal time in a clinic seeing the same number and acuity should be making 255k. Period.
Specializes in Psychiatric and Mental Health NP (PMHNP).
djmatte said:
Imo you should eat what you kill. We literally bill for 85% off what an MD bills for. That's where the value of their advanced degree should lie. Midlevels make a fraction of what they bring in while I've seen MDs break even or come well under what they actually make. Having a swarm of mid levels around 1-2 doctors in a clinic can bring in higher salaries which are more attractive to MDs who are harder to get in the door. It's economics, but not equity of value. Take your example. 10-12 mid levels per MD practically pays the salary for 3-4 doctors. And the clinic still makes money hand over fist even if that doctors sole task is to keep them undereducated mid levels in line. If an MD makes 300k a year, your mid level of equal time in a clinic seeing the same number and acuity should be making 255k. Period.
I understand your argument, but that is just not how compensation tends to work. It's not just "eating what you kill" in most professions, with the exception of sales-type positions.
Doctors and NPs are professionals like lawyers, accountants, and consultants. When a practice hires a consultant, for example, the pay is not just based on that person's anticipated billings, but also reflects their education and years of experience. A consultant right out of school is not going to make as much as a consultant with 10 years of experience, even if they are billing at the same rate.
Anyway, I think NPs in California are paid well overall. Unfortunately, that is not the case in most other states. I am not sure why that is.
There are more NP positions available from what I am seeing where compensation is based on splitting billings or on various productivity measures. And as more states have FPA, more NPs will have the opportunity to build their own practice and really maximize their earnings.
NPs can and should advocate for billing parity, like in OR.
I understand your argument, but that is just not how compensation tends to work. It's not just "eating what you kill" in most professions, with the exception of sales-type positions.
Doctors and NPs are professionals like lawyers, accountants, and consultants. When a practice hires a consultant, for example, the pay is not just based on that person's anticipated billings, but also reflects their education and years of experience. A consultant right out of school is not going to make as much as a consultant with 10 years of experience, even if they are billing at the same rate.
Anyway, I think NPs in California are paid well overall. Unfortunately, that is not the case in most other states. I am not sure why that is.
There are more NP positions available from what I am seeing where compensation is based on splitting billings or on various productivity measures. And as more states have FPA, more NPs will have the opportunity to build their own practice and really maximize their earnings.
NPs can and should advocate for billing parity, like in OR.
Billing parity isn't the issue. If I'm a NP with 5 years experience, see the same number of patients, see literally the same acuity of patients, I should be paid 85% of what an MD of equal standing in that clinic gets paid. Their "prestige" makes up for that 15% bump. Insurance companies decided that's what they value that additional education and that's what everyone else should value it. We are literally padding their salaries as the clinic eats a bit more of income on the doctors end.
Specializes in Psychiatric and Mental Health NP (PMHNP).
djmatte said:
Billing parity isn't the issue. If I'm a NP with 5 years experience, see the same number of patients, see literally the same acuity of patients, I should be paid 85% of what an MD of equal standing in that clinic gets paid. Their "prestige" makes up for that 15% bump. Insurance companies decided that's what they value that additional education and that's what everyone else should value it. We are literally padding their salaries as the clinic eats a bit more of income on the doctors end.
If NP work was reimbursed at the same rate as MDs, it would be a better case for NPs to demand more pay.
NPs are never going to be paid the same as MDs. Period. It's fruitless to pursue this.
If NP work was reimbursed at the same rate as MDs, it would be a better case for NPs to demand more pay.
NPs are never going to be paid the same as MDs. Period. It's fruitless to pursue this.
I'm not advocating for equal pay. I'm advocating for pay based on presumed value of the education level. If the reimbursement rates were the same then I would absolutely be advocating for equal pay. But even at 85% reimbursement, we're being paid 1/3 or less of the MD salary. We. Are. Being. Exploited.
MentalKlarity, BSN, NP
360 Posts
You're very welcome! I agree, there is more to the picture than pay - flexibility and work-life balance are so important! In my case, I made it clear to my employer I needed generous paid and unpaid vacation as I want to have vacation time - I actually took a slight paycut in exchange for some more flexibility with time off so I could enjoy my life and not just work.
That said, agree that many NPs simply do not know what they bring in and that is a big issue. I can tell you that the clinic I work in has a fairly low overhead (we have one MA and one front office person), the building rent is cheap, and there are numerous providers. I actually requested to review my collections with my employer and saw that on average the insurance companies were reimbursing at nearly $250+ per patient (2 per hour, so bringing in sometimes $500 an hour depending on their insurance provider) that I was seeing. I requested either an hourly rate that gave me a substantial portion of that, accounting for people who don't pay or don't show or have inferior insurance, or to give me a fair split of what I bring in. We settled on a split, which is at 75%. My employer is still making a profit off of me, and I am happy with that because everyone can win and benefit in the end. There is absolutely no reason why some nurse practitioners are out there billing for $300K-$500K or more depending on specialty and getting $100K in salary.
Ask yourself - why would clinics hire more nurse practitioners over physicians? Which brings more prestige, etc? It's because the physicians are asking for a salary that is closer to what they bringing in. Paying a physician who brings in $500K a salary of $375K is a LOT less attractive to a clinic than hiring an NP who bills for $400K but is happy at $120K salary. They can literally make double on the NP, because NPs do not know their worth like physicians do.