Nurse Practitioners, New Grads especially, be realistic about compensation

Specialties NP

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Nurse Practitioners, New Grads especially, be realistic about compensation

As a PMHNP who is also helping recruit NPs for our practice, I am running across new grads who have no idea what a realistic salary range is.  Especially for new grads, I strongly urge you to look at job boards and postings to get an idea for the salary range in your desired specialty and location.  This will allow you to make a realistic compensation request from future employers.  Asking for too much does not make a good impression on a prospective employer.  Hint:  If a pay range is given, as a new grad, do not ask for the high end of the range!  You are competing against NPs who may have 10 years or more experience in that specialty.  Those are the NPs that are going to get the highest pay.

Your NP Program should also give you some realistic pay ranges for a new grad of that program.  That's what my program did.  If they haven't done so, ask your advisor and professors for this info.  

For example, I had a NEW GRAD PMHNP based in the southeastern US, with NO psych experience, tell me they expected $100 per hour as a permanent employee with benefits.  That is $208K per year.  Uh, no, that isn't going to happen.  They would be lucky to get 50% of that where they live.  Given that I am in California, our practice would consider $80 to $85 per hour, with a good raise in 6 to 9 months, based on performance.

A suggested approach for discussing compensation during interviews:

1.  Look at the job boards for jobs in the area where you live or where the job is located (if you are willing to relocate or possibly for telehealth roles).  I have also posted compensation reports recently in a separate post.  Many jobs provide a compensation range.  For example, if you review job postings, the general pay range for a PMHNP in California (for employees, not 1099) appears to be in the $160 to $180K a year range, with some employers offering up to $200K to $220K per year, that gives you a pretty good idea of what you can reasonably ask for.  So, a new grad PMHNP could ask for $160K to $175K per year.  If that new PMHNP had prior psych experience, like they did a lot of psych as an FNP, then they could ask for more.  Don't ask for the middle or top of the range!  That just makes you look clueless.

2.  As a negotiating tactic, consider asking for a 6 month performance review with (you name your desired raise) at that time for good performance

3.  As another negotiating tactic, you might ask for a signing bonus.

4.  Or, instead of $, you might ask for something else.  For example, if you really want more PTO, ask for a little more of that instead of $.

5.  If you an experienced NP that has just changed specialties, then you are a new grad NP.  Sorry.  For example, you are an FNP that just earned their PMHNP.  If your FNP experience obviously includes little to no psych experience, don't expect top dollar!  (Yes, some FNPs do a lot of psych in primary care, but that is not true of all FNPs).  A new employer in psych would likely give you some credit for general NP experience, but you are not going to command top dollar because you just don't have relevant experience.

6.  If you are an experienced NP that has just changed specialties, and you also have work experience in the new specialty, make sure your resume and cover letter highlight that.  Be prepared to discuss this during the interview.  For example, a new PMHNP with 5 years FNP experience that treated a lot of psych conditions in primary care, and can back that up, can definitely expect credit for that relevant experience.  Even so, do not expect to get top dollar!  You could reasonably ask for comp in the middle of the stated range.

7.  Be aware that there are now some telehealth platforms that will advertise NP pay of up to $350K per year.  However, those are 1099 positions.  That's fine for experienced NPs who want to maximize earnings, and don't need benefits, but are not a good bet for new grads, as there won't be much, or any, coaching.  Those places are not also going to hand you 40 hours worth of appointments right away.

In addition to compensation, do the research on how most specialties operate, such as number of patients seen per day, etc.  This information shouldn't be hard to find - research via articles, blogs, ask professors/advisors, and contact alumni if you can.  For example, in California, it is pretty standard for both primary care and psych to have 20 minute follow up appointments and 40-50 minute intake appointments (most are 40 min).  I wish we had more time, but that is the current standard.  Many psych practices have 15 minute follow ups.  Normally, there is a ramp up period, so a new employee would not be expected to do this right off the bat (make sure that is the case).  So don't go into an interview requesting a 90 minute intake and 30 to 45 minute follow ups on an ongoing basis!  If this is a practice, then you will have to adhere to the practice standards.  Unrealistic expectations are going to make it very hard to find that first job.  I have seen some psych jobs where you can set your own schedule and if you want to have a 2 hour intake, fine, but those jobs are not common.

As a new grad NP, your goal is to get that first job and it should be a job that provides the best learning opportunity with reasonable pay.  If all you can get is crappy pay, then so be it.  After 1 year, you can go get a better job.

Note:  a decent practice will have a reasonable onboarding system and ramp up period.  Normally, it take 4 to 6 weeks for a provider to get fully up to speed and able to serve a full schedule.  Even an experienced provider has to learn the EMR and all the administrative aspects of their new practice.  Avoid any practice that does not have a reasonable system to get new hires up to speed.

Tip #1 for new grads:  If you want to maximize your earnings, do the research where there are shortages of providers in your specialty.  Those areas are going to pay more and you will be in a strong negotiating position.  Many such positions also offer loan repayment, sign on bonuses, relocation assistance, performance bonuses, and even mortgage subsidies.  You may have to relocate, but again, it is not necessarily forever.  Many NPs will commute to a job in such an area, rent a room there during the week, and then go home on weekends.  Some states, such as California, have overall shortages of RNs and NPs.  And within a state there are areas with shortages, most likely rural areas and smaller towns and cities.  The plus of that is that those areas typically have a lower cost of living.  And you may discover you really like it there!  I used to work in the North State of California (north of SF and Sacramento).  A lot of doctors and NPs work in a rural area during the week, then commute back home on weekends to Redding, Sacramento, or San Francisco Bay Area.  Also, some "rural" areas are only 30 to 60 minutes from a decent size town/city.  This is also a great way to find organizations that will fulfill public service requirements for HRSA scholarships or that are eligible for state/federal loan repayment programs.   I never thought I would want to live outside of L.A. or San Diego, but once I did, I realized I was sick of the traffic, crowds, and super high prices.  

I also want to make a pitch for rural areas.  Because my first job was in a very rural FQHC, we had to do a bit of everything.  That meant an incredible learning experience.  We just did not have the option of sending anything out of the ordinary to Urgent Care or the ER.  One of the clinics was literally next door to the small rural hospital, and it was an opportunity to develop close working relationships with the ER and even spend time there when it wasn't busy - another excellent learning opportunity.  In such a small community, providers get to know their patients very well and can truly practice holistic care by addressing socioeconomic aspects of health.  You will also truly be giving back.  

The providers in such areas tend to be very dedicated and many have incredibly prestigious backgrounds.  They are generally motivated to be excellent mentors because they want their community to have enough good providers.

Another miscellaneous tip:  There are positions where the provider has to build up a panel of patients.  That means 40 hours can't be guaranteed right off the bat.  Do not panic!  Frankly, especially for a new grad, that can be better by providing a ramp up period.  Find out how long it would take to build up a full patient panel.  If the answer is 1 to 2 months, then consider it may well be worth it, especially if the pay is good.  There are lot of ways NPs can have side gigs to get more hours temporarily or even permanently, such as a PT job or doing 1099 work such as veteran disability exams.  Let's say an FNP has just earned their PMHNP.  Their current employer might be happy to have that FNP continue working part time for awhile.  An NP currently making $45 per hour ($1,800 per week or $ 93,600 per year) working FT in a state with crappy pay would be better off making $75 per hour at 24 hours a week to start, with the ability to go up to 40 hours per week in 2 to 3 months.  ($75 per hour x 24 hours = $93,600 per year, at 32 hours = $124,800 year, at 40 hours = $156,000 per year).  In other words, do some basic math.

You may find that being able to work fewer hours for the same or greater annual pay is better for you.  This can be a big benefit for someone continuing their education, who wants to spend more time with their family, is in danger of burning out, or just wants more personal time.  It can also be an opportunity to have a lucrative side gig or build up one's own private practice while continuing to have decent income.  Let's say you are an PMHNP who wants to set up her own practice.  You could work PT for a practice, then start building your own practice on the side.  A lot of psychiatrists do this - they have a PT job, then also a PT private practice.

Also, a practice with flexibility on hours, that does not require providers to work 40 hours per week, is a benefit.  Are you planning to go back to school?  Planning to start a family?  Planning to slow down gradually before retiring?  Feeling burned out?  Have family members that require care, such as an aging parent?  Knowing that if you have to change your schedule, you can keep your job, can be a big plus.

Personally, when I started my current job, I was scheduled 2 days per week.  I did veteran disability exams on the side.  (That was good gig, as I could set my own hours - if I wanted to work on weekends, I could, and got paid on 1099).  I was going to be starting my PMHNP program soon, so I did not want to work more than 3 days per week.  As soon as I completed my PMHNP and was ready for more hours, I got them immediately.  Even working only 3 days per week, I was making more than I had been working FT in primary care.

There are plenty of posts here on how NPs can maximize their earnings, so it is not my intention to start another debate on that.  I am posting this for people who just need a regular job.  Best wishes to all.

Specializes in Psychiatry.

Why are you on here trying to suppress NP pay? 
 

many NP salaries are pitiful. Using job boards to set your pay expectation means letting low salaries stay. Why are you so against letting NPs force a better market wage? For every NP that accepts joke wages of a fraction of what they bring in, that's another employer who feels they never need to pay more. As the market saturates with for profit graduates we should be doing anything BUT accepting low wages and telling other new grads to do the same!!

FullGlass, BSN, MSN, NP

2 Articles; 1,698 Posts

Specializes in Psychiatric and Mental Health NP (PMHNP).
MentalKlarity said:

Why are you on here trying to suppress NP pay? 
 

many NP salaries are pitiful. Using job boards to set your pay expectation means letting low salaries stay. Why are you so against letting NPs force a better market wage? For every NP that accepts joke wages of a fraction of what they bring in, that's another employer who feels they never need to pay more. As the market saturates with for profit graduates we should be doing anything BUT accepting low wages and telling other new grads to do the same!!

Please just stop.  Most of my post is focused on new grad NPs. They do not deserve top dollar. End of story.

While I appreciate some of your suggestions, you may be doing a profound disservice to many NPs.  I am being realistic.  A lot of people need to get a job.  They don't have time to screw around.  If someone needs to get a job quickly, then they need to ask for a reasonable compensation based on the market.  End of story.  Someone who goes in demanding the kind of pay you are talking about is also competing against other applicants.  Why on earth would an employer offer super high pay to an unknown quantity when they can hire other, equally qualified candidates for the market rate?

Now, if someone has experience and is a good provider, then that is when it makes sense to go to one's employer to ask for more money.

Any new grad NP that tells me they expect $100 per hour is deluded.  New grad NPs are not as productive as experienced NPs.  They go through an onboarding process and need a lot of hand holding.  It takes at least 6 months for them to be fully productive; many require 1 year to achieve this.  So they do not deserve top dollar during that period.  

It takes about 10,000 hours of doing something to become an "expert."  That is about 5 years.  We also provide higher pay to providers with more experience because they have greater expertise.  

Your advice is just not applicable to many NPs.  Also, have you considered that an NP who asks for too much money could end up losing their job?  If an employer feels the NP has them over a barrel, they may give the higher pay, but they could then look around for a cheaper replacement.  Most states are "right to work," meaning an employee can be fired for just about any reason.  This just happened to a psychiatrist I know.  He negotiated, by his own admission, an extremely high pay rate with a clinic because he knew the clinic was desperate.  HIs contract just came up for renewal and it was not renewed.  The clinic replaced him with 2 "new" psychiatrists (not NPs).

In addition, if an NP demands the equivalent of MD pay, an employer could very well decide they might as well get themselves an MD.

Your advice is helpful to an experienced NP who has been working somewhere for awhile and is a proven performer.  Even then, like it or not, the employer can simply refuse to increase their pay.  

Granted, I am in California, where RNs and NPs are paid the highest in the U.S.  I am fine with what I make for now.  There are parts of the country where NP pay is crappy, but I honestly don't know how your suggestions are going to help.  If the average NP pay in CRAP state is $90K per year, do you honestly think an individual NP in that state making the average pay and then demanding $200K per year is going to fly?  No, it isn't.  The employer can simply say no and hire another NP to replace them.

Asking for the type of money you advocate for, successfully, is predicated on how receptive the employer is.  A doctor who owns a private practice might be open to this, but they might not be.  An NP working in a large organization like Kaiser, with a big bureaucracy, is stuck with the pay scales of that organization.  An employer may also be worried that if they grant you this type of pay, then all the other NPs and PAs are going to demand the same.

Personally, I think RNs and NPs in states with crappy pay need to organize and get themselves a union.  In addition, they need to force their professional associations to legally advocate for legislation enforcing adequate nurse-patient ratios.  NPs also need to really push for Medicare reimbursement equality.  Frankly, our associations don't do a great job.  There are way more nurses and NPs in total than there are doctors, but the AMA and other medical associations have generally been much more effective in advocating for doctors.

Right now, about half of US states have FPA for NPs.  NPs in those states are free to hang out their own shingle and charge whatever the market will bear.  However, NPs in states w/o FPA do not have that option and must have a supervising physician.  Those NPs are in a more difficult situation.

I don't know about the rest of you, but when I need to get a new job, I need to hustle.  I don't have the luxury of waiting for 6 months to a year to get the "perfect" job with fantastic pay, great benefits, spending 1 hour per patient, etc.  That job doesn't even exist (I don't mean one's own practice, but a job as an employee).

There is a business saying, when you are looking to buy a product or service:  "You can have low price, high quality, fast delivery - you can get 2 out of the 3, but never all 3."  That is also true of jobs.  An NP has to prioritize what they want/need from a job and be realistic.  Want great job security with outstanding benefits?  In California, working for the State will get you that (includes counties).  But the pay will not be very high.  Just focused on maximizing earnings?  OK, but the way to do that is 1099 or your own practice.  That means no benefits.  Someone setting up their own practice is going to work like a dog for at least 3 years to get it established, 50 to 60 hours per week or more.  That sacrifice is well worth it in the long run financially, but an NP who is a single mother with 2 young children probably can't do that, at least not until her children are older.  Individuals that place a high priority on their family life do not want to work long hours, in general.

The states that pay better tend to have shortages of RNs and/or providers.  That is why they are paying more, to attract candidates from other states.  In other words, supply and demand.  If I want to hire an NP, and offer $100K per year and get no takers, then I will have to raise the pay to see if I can get good candidates that way.  However, if I offer $100K per year and get 3 solid candidates, then I'm going to pay $100K per year.  As an NP who needs a job, one needs to realistic about the NP labor market where they plan to live and work.

Even MDs are grappling with lower pay.  Emergency Room MDs have been offered lower and lower pay, as low as $15 per hour.  That is because the ER is typically a loss leader and many hospitals have outsourced the ER.

https://sullivanlegal.us/denver-hospital-offering-emergency-physician-21-per-hour/

In summary, I believe the long-run solution to better NP compensation is:

1.  Collective action, I.e. unions

2.  Reimbursement parity

3.  FPA

4.  NPs voting with their feet and leaving crappy pay states.  When those states have a shortage of providers, they will have to increase pay.

An NP considering taking your compensation negotiation advice needs to be realistic and answer the following questions:

1.  Have I been here long enough to prove I am a good performer?

2.  Is this an organization that might be receptive to a new type of comp package for me?  (Hint: if you work for a large organization or the government, the answer is no).

3.  If you work for a private practice or small organization that can be more flexible in setting pay, will they be receptive to this type of package for me?  What will I do if they say no?  You really have to know your employer on this one.  Some employers may see you as a malcontent and look for a replacement.  If you are OK with that, fine, but most people need steady employment.

4.  Can I be easily replaced by a provider making the market comp?  If the answer is yes, then you have way less negotiating power.

 

FullGlass, BSN, MSN, NP

2 Articles; 1,698 Posts

Specializes in Psychiatric and Mental Health NP (PMHNP).

I also want to discuss overhead.  Many NPs do not seem to understand the overhead expenses in a medical practice.  Psych has very low overhead, usually, because all you need is an office (or can work from home via telehealth), a computer, a decent EMR, and high speed internet.  However, large psych practices will likely need medical assistants, billing (unless the practice is only cash pay), etc.  While billing can be outsourced, it is not free.  In some mental health organizations, because talk therapy is reimbursed by insurance at such crappy rates, providers are subsidizing talk therapist pay a bit so the organization can hire talk therapists that accept insurance.

However, other specialties have a LOT of overhead.  I worked closely with a pain management doctor who owned his own practice.

1.  Office space - has to be in a decent area, typically in an area with other medical offices, near a hospital, etc.  Nice area = more $ for rent

2.  Medical assistant(s), receptionist.  They have to be paid and if you want to keep them, paid decently.

3.  Office furniture

4.  Office equipment - this can be a huge expense.  This pain specialist had 2 large, specialized machines, I forget what they were called.  That's not cheap.  Even those exam tables that patients sit/lie on are not cheap.  Primary care:  otoscope, etc. on the wall, equipment to take temp, BP, scales for weight, etc.

5.  Office supplies, medical supplies - think of all the medical supplies a primary care office has to keep on hand - bandages, antiseptic solution, wound washes, needles, vaccines, etc.

6.  EMR and telecommunications - these expenses can get pretty high

7.  Billing.  While this can be outsourced, it isn't free.

8.  Insurance

9.  Salaries for employed providers

10.  Cost of benefits for employees - paying them when they are sick, on vacation, etc.  Health insurance (costs of this are skyrocketing), etc.

11.  Profit.  Yes, owners deserve profit.  First, a business needs some "savings" for unexpected expenses or to ride out rough times.  Second, MDs that start a private practice don't just hang out a shingle and have a boat load of patients.  It takes 3 to 5 years to build a solid practice.  During that time, the MD is not making much money.  They are also working a lot, not just seeing patients, but working to get more patients - going to association meetings, conferences, meeting with organizations that can refer patients, holding seminars, writing blogs, etc., speaking to prospective patients in places like churches, nursing homes, etc.  They deserve compensation for that after their practice is established.

Most MDs I know work like dogs.  This pain doctor was the first in the office and the last to leave.  While he made sure his employees had a lunch break, he usually did not.  He might gobble down a sandwich in 5 minutes so he could keep working.  I really felt bad for him, because he focused on doing procedures to max income (NPs or PAs handled most appts that did not require a procedure).  He had to stand almost all day, wearing a heavy lead apron to shield from radiation from the equipment.  As a result, he developed severe back pain himself.  Was he living high on the hog?  No.  He drove a normal car, something like a Toyota Camry (his wife had a Lexus).  He had a very nice home, but he also bought that a long time ago, when real estate was much cheaper.  He had made an effort to provide his services at a more affordable rate, because he was truly committed to helping underserved peoples.  He was actually losing money, and wanted to sell his practice - being an employee would be a lot easier for him.  That's what he ended up doing.

In short, it takes a long time to build a successful practice, and frankly, it is a pain to run one.  That is why fewer and fewer doctors want to own their own practice.  Not everyone has what it takes to build their own practice, or the desire to do so. Most of us just want to go to work, do our job, and then go home.  Yes, a practice owner should treat employees well and pay them well, but they also deserve to make a profit.  I do not begrudge them that.

Specializes in Psychiatry.

Have you ever stop to realize that if new grads accept peanuts for pay it will suppress ALL OF OUR SALARIES? You can say what you want about productivity, and learning, etc, but I would be MORE THAN HAPPY if every NP demanded $100+ an hour because then experienced NPs can demand $150+ an hour. If everyone follows you advice and takes the first offer they are given, telling themselves "I'm new, I can be taken advantage of" then they will accept $60 an hour, be lucky to hit $80 after 5 years, and when those of us with a ton of experience apply the employer will say "Sorry, our NPs make $60-80 so at best we can give you $85 for your experience!"

Your posts are not helpful to the profession. We already have saturation issues and more than enough for-profit graduates accepting low paying positions. We don't need to preach to the next generation that they, too, should be doing everything they can to suppress our reputations, market, and salary even further.

Could you imagine a post on a physician forum telling new graduate MDs to "take LOW OFFERS! YOU AREN'T WORTH IT!" Good grief!

 

One thing that really stuck out in your post was this:

Quote

If an employer feels the NP has them over a barrel, they may give the higher pay, but they could then look around for a cheaper replacement.  

This applies to EVERYONE. An employer will always be on the lookout for a cheaper replacement. YOU out here encouraging every graduating NP in America to BECOME that cheaper replacement is hurting all of us experienced NPs.

FullGlass, BSN, MSN, NP

2 Articles; 1,698 Posts

Specializes in Psychiatric and Mental Health NP (PMHNP).

No, I am being realistic.  

You are speaking in hypotheticals, not in reality.  Let's closely examine your logic:

"if every NP demanded $100+ an hour because then experienced NPs can demand $150+ an hour"   How on earth do you propose to make this happen?  Posting on this forum is not going to make this happen.  Even if this were somewhat possible, there will always be some people who will take the lower pay so they can get a job.  The only way to make something like this happen is through collective bargaining - a union.  I happen to think a union is a good idea, but that is going to take a lot of work and is not going to happen overnight.

"We already have saturation issues and more than enough for-profit graduates accepting low paying positions."  Maybe in some areas, but certainly not nationally.  Certain states, like the West Coast states have severe shortages of primary care and mental health providers of all levels.  Even within "saturated" states there are shortages in certain areas.  I simply fail to understand why people here keep insisting there is saturation.  The evidence does not support that.  There is a shortage of primary care MDs and psychiatrists and that is only going to get worse.  As a result, more NPs will be utilized in these specialties.  But there is also a shortage of NPs in many locations!  An NP can move to an area with a shortage that pays better.  It is a free country.  PMHNPs can work remotely, so can serve any area in the country, as long as they obtain the needed licenses.

"This applies to EVERYONE. An employer will always be on the lookout for a cheaper replacement. YOU out here encouraging every graduating NP in America to BECOME that cheaper replacement is hurting all of us experienced NPs."  No, it isn't.  It is very hard for new grad NPs to get that first job.  Most employers prefer experienced candidates, because they can hit the ground running.  I am trying to help new grad NPs actually get a job within a reasonable period of time.

Frankly, I don't know what planet you are living on.  In Silicon Valley, even with all the hype, starting programmer pay can be in the $150 to $180K range.  You are proposing new grad NPs get even more than that!  LOL  That is not going to happen here in the dimension the rest of us are living in.

The purpose of my posts are not to engage in theoretical debates about the future of the profession.  My goal is to help people get a decent job for decent pay as fast as possible.

Oh, and your approach to negotiating pay would require a candidate to ask a prospective employer for all their financial data.  Why on earth would anyone hand an unknown quantity that kind of info?  They aren't going to, and such a request is likely going to result in that candidate being written off.  Your approach will only work for an NP that is already working there and is a good performer.

I have discussed how NPs could raise their pay, but in order to do that at a macro level, it requires organization and time.  That is not my focus in this original post.

Realism will happen when employers put their providers in appropriate proportions of what they bring in. It's understandable if a nurse practitioner makes 15% less than a provider does given the same total number of patients and the same complexity of care being given. Newer grads are expected to make less, but that's under the circumstances that they are either billing for less or they are not seeing as many patients, given the nature of a "ramp up" or not finding a patient empanelment that sees the patient regularly or justifies a salary. if a Dr brings in $500,000 worth of billing a year, factoring in overhead and other, nursing staff, they should make X percentage of that grouping. Nurse practitioner should be making 15% less than that given the recommended and reimbursement rates typical of most insurance companies. again,

 Again, new nurse practitioners can potentially make les. But their patient ratio and use of answering services better damn well reflect that pay difference. Well, ability is a factor in most of these discussions, reimbursement doesn't give two craps whether you are a new nurse practitioner or somebody who's been one for over 20 years. The difference is likely the person understanding the difference of what they bill and how they bill.

Hoosier_RN, MSN

3,956 Posts

Specializes in Dialysis.

@FullGlass, great thread! I'm not an NP, but this is great advice for even newly minted nurses. I've interviewed 3 new RN grads in the last 6 months, all expected at least $5/hr more than my highest paid staff member that has years of experience. All told me that they interviewed at local hospital, but didn't want to work bedside, not realizing that I know I know the managers and HR folks. All 3 had demanded exorbitant rates there and were passed over for candidates with more realistic expectations. 

It's not mean, or demeaning, to put out that experience brings compensation, and that is a reality. Be it for NP, RN, or any other job class

BTW, 1 of the 3 candidates is still working as a store clerk, as she's refused the jobs that actually did interview her. Sad that she's boxed herself in at this time

Hoosier_RN said:

@FullGlass, great thread! I'm not an NP, but this is great advice for even newly minted nurses. I've interviewed 3 new RN grads in the last 6 months, all expected at least $5/hr more than my highest paid staff member that has years of experience. All told me that they interviewed at local hospital, but didn't want to work bedside, not realizing that I know I know the managers and HR folks. All 3 had demanded exorbitant rates there and were passed over for candidates with more realistic expectations. 

It's not mean, or demeaning, to put out that experience brings compensation, and that is a reality. Be it for NP, RN, or any other job class

BTW, 1 of the 3 candidates is still working as a store clerk, as she's refused the jobs that actually did interview her. Sad that she's boxed herself in at this time

There often is a difference though between NPs in clinics and RNs in hospitals or other areas. We actually bill and are revenue generators. It's been my experience when I worked as an RN most hospitals have tiered systems built in to account for experience of new hires. It's rare to see negotiating outside of more management level jobs. Mind you I'm mostly talking about hourly jobs. Salary positions obviously have some different negotiating capacities, but still often minimal. 

On our end though, recognizing what you bring in is part of the game. Many clinics can justify paying a new NP at lower levels because to some degree they're more reliant on other staff as they make decisions or often just don't see the same numbers of patients/bill to the optimal level. Any new hire (regardless of experience) also are an expense as they build their own panel and get better rapport with existing patients. This is a common theme for mid levels. But it's rare they hire a doctor and suggest that doc take a pay cut because he's a net loss the first year or two. They on average pay whatever gets that MD in the clinic while mid levels are paid a third or less of what they actually bill for. 

Hoosier_RN, MSN

3,956 Posts

Specializes in Dialysis.
djmatte said:

There often is a difference though between NPs in clinics and RNs in hospitals or other areas. We actually bill and are revenue generators. It's been my experience when I worked as an RN most hospitals have tiered systems built in to account for experience of new hires. It's rare to see negotiating outside of more management level jobs. Mind you I'm mostly talking about hourly jobs. Salary positions obviously have some different negotiating capacities, but still often minimal. 

On our end though, recognizing what you bring in is part of the game. Many clinics can justify paying a new NP at lower levels because to some degree they're more reliant on other staff as they make decisions or often just don't see the same numbers of patients/bill to the optimal level. Any new hire (regardless of experience) also are an expense as they build their own panel and get better rapport with existing patients. This is a common theme for mid levels. But it's rare they hire a doctor and suggest that doc take a pay cut because he's a net loss the first year or two. They on average pay whatever gets that MD in the clinic while mid levels are paid a third or less of what they actually bill for. 

We all get that. I was just pointing out this new mindset that brand new, no experience persons seem to think that they should be making top tier money simply because they exist, and this thread is a good representation of that. I would never dare to think that a RN would be in the same realm as an NP, although to be a NP you must be a RN, sorry that you thought I couldn't make the distinction. Realistically,  RNs with experience can discuss what they bring to the table to justify asking for more

I didn't presume you couldn't make the distinction. But to be fair, the OP never worked as an RN. So distinguishing these things doesn't hurt. 

FullGlass, BSN, MSN, NP

2 Articles; 1,698 Posts

Specializes in Psychiatric and Mental Health NP (PMHNP).
djmatte said:

Realism will happen when employers put their providers in appropriate proportions of what they bring in. It's understandable if a nurse practitioner makes 15% less than a provider does given the same total number of patients and the same complexity of care being given. Newer grads are expected to make less, but that's under the circumstances that they are either billing for less or they are not seeing as many patients, given the nature of a "ramp up" or not finding a patient empanelment that sees the patient regularly or justifies a salary. if a Dr brings in $500,000 worth of billing a year, factoring in overhead and other, nursing staff, they should make X percentage of that grouping. Nurse practitioner should be making 15% less than that given the recommended and reimbursement rates typical of most insurance companies. again,

 Again, new nurse practitioners can potentially make les. But their patient ratio and use of answering services better damn well reflect that pay difference. Well, ability is a factor in most of these discussions, reimbursement doesn't give two craps whether you are a new nurse practitioner or somebody who's been one for over 20 years. The difference is likely the person understanding the difference of what they bill and how they bill.

My goal in starting this thread is to help NPs get a job, especially new grad NPs.  Raising NP pay overall was not the purpose of my post, as there are other discussions on that topic.  In previous posts on this thread, I discussed what needs to happen for NP pay to increase at the macro level.  It will take a lot of time, organization, and effort.  So that is not going to help an NP trying to find a job now.

Currently, for PMHNPs, there are telehealth platforms that will enable a PMHNP to make up to $350K per year or so.  Those platforms pay the NP a % of billings.  However, it will take a while to build a patient panel and there are no benefits.  This is also not suitable employment for a new grad PMHNP, as there is little to no guidance/supervision.

There are some psych practices that pay based on a split of 70/30 or 60/40.  However, they are in the minority.  But it is certainly an option available to PMHNPs who are not in a hurry to find a new job.   I spoke with a psychiatrist about this, and he said that in his experience, it ends up being a big hassle and the provider kind of gets screwed.  MentalKlarity, however, was able to negotiate such an arrangement with their employer and is very happy.

For non-psych NPs, I have seen practices that pay based on RVUs and have good performance bonuses.  I'm sure there are opportunities for NPs to work for an employer that does a split.  It's just those positions are not the majority of openings.

For all the complaints of lack of fairness in pay, well, life isn't fair.  Furthermore, MDs really do pay their dues compared to NPs:

1.  MDs work like dogs most of their young lives before college so they can good grades and get into the best college possible.  Compare that to the attitude of many RNs and NPs that they don't need to do that and that going to a good school versus a crap for-profit school doesn't matter.   (Good school = any public community college, college, university or a good nonprofit college/university nursing school).  

2.  A future MD also has to work like a dog in college in order to get into a good medical school, or pretty much any medical school.  Hate to break it to some of you, but it is a lot harder to get good grades at Harvard, Yale, or UCLA than at University of Phoenix.

3.  Medical school is very difficult, and it is 4 years, versus 2 years for an MSN NP.  DNPs as currently constituted are not clinical and don't count in a comparison against med school.  NP school in general is nowhere near as hard as medical school and NPs get a very low amount of clinical hours compared to med students.

4.  Newly graduated MDs must do 4-5 years of internship and residency, and many also do fellowships.  They get paid crap during this period - $40-50K annually during internship, $60-$80K annually during residency and fellowship.  This is very intense clinical training, with long hours.  While there are some NP residencies, there are very few and they are nowhere near as intense.  They also end up with a huge amount of student debt compared to NPs.

A "new" MD or DO that has completed an internship/residency and fellowship already has at least 4 years of experience; many have up to 10 years experience.

Organizations also have to pay newer MDs more because of medical school debt.  If they didn't, well, we'd end up with no MDs.  There would be no reason for anyone to go to medical school.

So sorry, a new grad NP does not have anywhere near the education, training, or experience of a "new" MD.  The new MD deserves more money for their experience and expertise.  

In addition, in many specialties, NPs and PAs perform mundane care.  The MDs are focused on more lucrative procedures that NPs simply can't perform.  This is another reason MDs make more money.  Among the highest paid MDs are surgeons.  Well, NPs can't perform surgery.

CRNAs are the overall highest paid NPs b/c they are working in surgery.  There are also some NPs in specialties like derm and aesthetics making $200K up to $500K per year.  Those are procedures-based and partly cash pay.

I also want to circle back to education.  If you look at the highest paid professions, school does indeed matter.  Take law - future lawyers also work their butts off to go to a good college, then the best law school they can get into.  The best law firms (AmLaw 100) then recruit from the best law schools and starting pay can be $180K year or more.  However, most lawyers don't make huge sums.   It's the lawyers that work for the best firms and make partner that make the big bucks.  An exception are successful litigators.

Business - here are the 3 ways to make a boatload of money in business:

1.  Start your own business and work like a dog to make it successful.  That's way more work than it takes to become an NP, with years of sacrifice.  No college degree required.

2.  Again, work like a dog to get into a good college, then a good MBA program.  The elite graduates then go work on Wall Street or for elite consultancies like McKinsey, BCG, Bain, etc.  They can make less, but still a good amount, for other large firms like Accenture, etc.  Once they make partner, or the equivalent, then they make huge bucks.

3.  Sales.  Learn to become an excellent salesperson and you can make over $1 million per year, or close to it, in any industry.  However, again, it is very hard work, a lot more work than being an NP.  In some industries, no college degree required.

High tech - this is really business, but a lot of healthcare people seem to think that tech people are rolling in money.  Some are, true, but those are the ones that started a successful business, or part of the start up team after a successful IPO.  Software engineers can start at around $180K in Silicon Valley, but it is ridiculously expensive to live there.  People in the Valley work like dogs.  I used to be one of them.  How about 10-14 hour days M-F, and also working on weekends, with no overtime?  Being expected to be on call and responsive to messages/emails almost 24/7?  During "crunch" periods before deadlines, pulling multiple all-nighters?  And often being horribly abused, way more than anyone on this forum can imagine.  

I took a pay cut to become an NP, but am much happier and healthier for it.

While I agree that NPs in some states, primarily the Southeast, are paid poorly, in many states NP pay is good.  The average salary in the U.S. is $75K per year. In many states, NPs can make $200K a year or more.  I'd say that's quite good, considering that NP education, training, and work effort in no way compares to that required to become a member of other professions.  And those NPs determined to make more $ have ways to do that.  My advice is to stop obsessing over what MDs make and focus on oneself and how to maximize personal opportunities.  If I worked FT, I'd make $208K per year.  I think that is quite good.  Most Americans would be happy to make that.

Those who want to effect change at the macro level are free to do so by becoming active in NP organizations, working for a union, and political advocacy.

Pigs get fat, hogs get slaughtered.

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