Nurse Practitioners, New Grads especially, be realistic about compensation

MentalKlarity, BSN, NP · Sep 28, 2023

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 · Sep 28, 2023

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 · Sep 28, 2023

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.

MentalKlarity, BSN, NP · Sep 29, 2023

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 · Sep 29, 2023

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.

djmatte, ADN, MSN, RN, NP · Oct 1, 2023

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 · Oct 1, 2023

@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

djmatte, ADN, MSN, RN, NP · Oct 1, 2023

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 · Oct 1, 2023

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

djmatte, ADN, MSN, RN, NP · Oct 1, 2023

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 · Oct 1, 2023

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.

Nurse Practitioners, New Grads especially, be realistic about compensation

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