Rural Midlevel Abuse

allnurses Guide · Mar 14, 2007

I work in a rural hospital and we don't have PA's or NP's in the ER.

Our docs take turn with ER call and do their clinic time . . . and the weekend doc on call starts at 5:30 p.m. on Friday and is off call on Monday at 8 a.m. So, all weekend this doc is at the beck and call of the emergency room. They sleep in a room on campus, just a few feet from the ER door. We wake them up at all hours. I am not sure how much money they make but I wouldn't do it for a million dollars.

steph

platon20 · Mar 15, 2007

"Fair wage" is whatever the market will bear. If a hospital doesnt offer a pay package that you like, then go elsewhere. That competition for jobs will force them to raise wages.

Or an even better option for an NP is to start up your own clinic. Then you can make however much money you want!

cgfnp · Mar 15, 2007

"Fair wage" is whatever the market will bear. If a hospital doesnt offer a pay package that you like, then go elsewhere. That competition for jobs will force them to raise wages.
Or an even better option for an NP is to start up your own clinic. Then you can make however much money you want!

This is true, and what I am trying to change. It will only change if we wake up the zombie midlevels who are just sheep and don't even realize what they are worth. And don't anyone try to tell me this isn't true because the low-ball offers wouldn't be out there if it weren't. Those of you who are "happy cause it's more than I was making as a RN" can go back to being a RN because those who are accepting pull the rug out from under those of us who are trying to standardize decent wages.

You are also correct in the starting your own clinic statement... as this is the one of the only ways to get paid fairly for what you do. But, I suspect most NPs don't want to do that because of fear of risk, and some can't because the states they are in suck (they technically can, but the laws some places make it much tougher). If we can teach NP/PAs to laugh in the face of offers that are rediculous as described in previous posts, the hospitals will be forced to pay better.

pegbord · Mar 15, 2007

cgfnp --- you are so right!! some of these rediculously low wages that are offered - and accepted only perpetuate the lack of respect that non-advanced registered nurses receive. as advanced practice registered nurses, the wage should reflect billable services ---- the hope being that one day registered nurses will also be seen as an asset rather than a commodity that takes away from hospital profit.

cgfnp · Mar 19, 2007

I like your idea about forming a union for NP/PA's. I think it is needed, and would be very effective. Too many new grads are sheep, don't do the research or even know about reimbursement issues, etc. As they say, people in medicine are often bad at business decision making.
I'm so burnt out right now that I wonder if I will even be interested in doing this when I'm done. Did you ever feel that? As I research rural positions here in Washington (thinking HRSA loan repay) I see some that are call 1:5, pay around 57,000 for a new grad, and think they are giving you a "deal" because they are offereing 3 weeks vacation. Well, I guess folks are taking these positions, or I think they would have to raise the $$.
Anyway, I think the union is a great idea.

I had to edit this because you don't have enough room to accept PMs brownrice.

Hi Brownrice. I know how you feel. Hang in there. You are just jumping through hoops. Just keep your head down and your eyes forward until you get the degree.

$57K is God awful. I hope you can find something better than that. You should start talking to your classmates and NP/PA friends about agreeing not to take jobs like that. That is less than half of what they would pay a doc in the same position doing the same thing billing out the same. If I were you, I'd ask that in the interview. Just politely say, "How do you explain the salary at less than half of that of a physician when although their training is longer and their expertise is greater, they bill out the same as we do using the same codes?" Another question I'd ask is "Which six months do I work here, the first or second half of the year, since the salary is about half what it should be?" That one might not go over well... might save that one for a place you're sure you're not going to work at. But those are the responses we need to give them so they rethink these offers. And, keep in mind that it is illegal for them to offer lower salaries because they are Loan Repayment sites (or at least they would lose their site status).

Regardless, if you have no choice but to accept one of these, make sure you get a productivity clause written in your contract up front. If your base is only $57K/yr, then I'd say I want 1/3 of the collected revenue for your services over 40 patients per week or eight per day. That's more than fair and if there is any way you can possibly turn them down if they balk at that then do it and go elsewhere. And for God sakes don't take call unless they pay you extra for it. Take these points to the interview: 1. The average family practice NP in the US does NOT take call and makes around $80K/yr. So if you take $57K, I'd ask for an hourly wage for call. I think $40/hr is fair. If you take an additional salary instead of hourly, you'll be sorry, as you'll end up taking more call and getting nothing in return for it. That's a mistake I made coming to Kansas. I'm in the process of trying to fix it, but it's much tougher to fix after it's already started.

Bottom line is the only way to fix this rediculous pay situation is to make it known everywhere that we won't take those peanuts any more. The average RN makes around $57K/yr. Give me a break!!!

And yes, I felt like getting out of the healthcare field every day of my terrible NP program. But then, I'd look over at my buddy who felt the same way and we'd laugh and start playing cards or reading medical journals and that kept us going.

core0 · Mar 19, 2007

I had to edit this because you don't have enough room to accept PMs brownrice.
Hi Brownrice. I know how you feel. Hang in there. You are just jumping through hoops. Just keep your head down and your eyes forward until you get the degree.
$57K is God awful. I hope you can find something better than that. You should start talking to your classmates and NP/PA friends about agreeing not to take jobs like that. That is less than half of what they would pay a doc in the same position doing the same thing billing out the same. If I were you, I'd ask that in the interview. Just politely say, "How do you explain the salary at less than half of that of a physician when although their training is longer and their expertise is greater, they bill out the same as we do using the same codes?" Another question I'd ask is "Which six months do I work here, the first or second half of the year, since the salary is about half what it should be?" That one might not go over well... might save that one for a place you're sure you're not going to work at. But those are the responses we need to give them so they rethink these offers. And, keep in mind that it is illegal for them to offer lower salaries because they are Loan Repayment sites (or at least they would lose their site status).
Regardless, if you have no choice but to accept one of these, make sure you get a productivity clause written in your contract up front. If your base is only $57K/yr, then I'd say I want 1/3 of the collected revenue for your services over 40 patients per week or eight per day. That's more than fair and if there is any way you can possibly turn them down if they balk at that then do it and go elsewhere. And for God sakes don't take call unless they pay you extra for it. Take these points to the interview: 1. The average family practice NP in the US does NOT take call and makes around $80K/yr. So if you take $57K, I'd ask for an hourly wage for call. I think $40/hr is fair. If you take an additional salary instead of hourly, you'll be sorry, as you'll end up taking more call and getting nothing in return for it. That's a mistake I made coming to Kansas. I'm in the process of trying to fix it, but it's much tougher to fix after it's already started.
Bottom line is the only way to fix this rediculous pay situation is to make it known everywhere that we won't take those peanuts any more. The average RN makes around $57K/yr. Give me a break!!!
And yes, I felt like getting out of the healthcare field every day of my terrible NP program. But then, I'd look over at my buddy who felt the same way and we'd laugh and start playing cards or reading medical journals and that kept us going.

As a new grad I am sure that abusing the recruiters will get a lot of job offers. The way to get the proper pay is to go in armed with the average pay for the position. The other thing that you have to look at is the situation. If you are looking at a Critical Access Hospital or Rural health care situation then that may be reasonable. They may offer you 1/3 of your collections that may be much less than 57k per year. Also for rural physicians 57K is about 2/3 of what many of them make. There are some cases where rural providers do abuse NPP's, but a lot of these places are barely scraping by. Every dollar for salaries comes out of some other part of the budget whether it is nursing or supplies or electricity. This is why you frequently see rotating J-1 visas at these sites. The average NP new grad salary seems to be around $63-68k looking around. 57k for a new grad in a rural area is not far off from that.

My advice to any new grad is get a job. You have more negotiating power with a year or two under your belt. As long as the pay isn't awful and you are not asked to do anything illegal/unethical do what you need to do.

David Carpenter, PA-C

cgfnp · Mar 19, 2007

As a new grad I am sure that abusing the recruiters will get a lot of job offers. The way to get the proper pay is to go in armed with the average pay for the position. The other thing that you have to look at is the situation. If you are looking at a Critical Access Hospital or Rural health care situation then that may be reasonable. They may offer you 1/3 of your collections that may be much less than 57k per year. Also for rural physicians 57K is about 2/3 of what many of them make. There are some cases where rural providers do abuse NPP's, but a lot of these places are barely scraping by. Every dollar for salaries comes out of some other part of the budget whether it is nursing or supplies or electricity. This is why you frequently see rotating J-1 visas at these sites. The average NP new grad salary seems to be around $63-68k looking around. 57k for a new grad in a rural area is not far off from that.
My advice to any new grad is get a job. You have more negotiating power with a year or two under your belt. As long as the pay isn't awful and you are not asked to do anything illegal/unethical do what you need to do.
David Carpenter, PA-C

The money is there in rural healthcare now. Reimbursements are among the best in primary care. I work in one of the most rural parts of the country at a clinic/hospital in a town of 1200 and there are plenty of opportunities to bill out for more than enough to make a salary of $57K/yr rediculous. If you are billing out $171K/yr, you are asleep at the wheel.

It's true that some places are scraping by despite the rural health reimbursement changes lately, but don't let them tell you that to justify a rediculous salary. If you ask for a productivity clause on top of your salary, no matter what it is, it provides them absolutely no more risk. If your situation at a particular clinic doesn't jive with seeing enough patients to make what you want, then change it. Have a lazy nurse? Get a new one! Don't have enough time? Find ways to become more efficient! Extend the hours! Can't do any of this because administration won't let you? (should never be the case if you show them this will result in more $$$ for the hospital). Open your own clinic!

core0 · Mar 19, 2007

The money is there in rural healthcare now. Reimbursements are among the best in primary care. I work in one of the most rural parts of the country at a clinic/hospital in a town of 1200 and there are plenty of opportunities to bill out for more than enough to make a salary of $57K/yr rediculous. If you are billing out $171K/yr, you are asleep at the wheel.
It's true that some places are scraping by despite the rural health reimbursement changes lately, but don't let them tell you that to justify a rediculous salary. If you ask for a productivity clause on top of your salary, no matter what it is, it provides them absolutely no more risk. If your situation at a particular clinic doesn't jive with seeing enough patients to make what you want, then change it. Have a lazy nurse? Get a new one! Don't have enough time? Find ways to become more efficient! Extend the hours! Can't do any of this because administration won't let you? (should never be the case if you show them this will result in more $$$ for the hospital). Open your own clinic!

I am somewhat confused. In your previous post you seem to imply that you are an NP student. Here you state that you work in a rural clinic. Which is it? Just because you interpret the situation in your town don't assume that it applies everywhere. In Eastern Colorado the medicaid/no insurance rate is truly staggering. Billing isn't going to be much here. If you look at the average income for PA's in rural FP the range is $1 to $150k. The person that is making $1 is a retired Navy Commander that pays herself a token dollar. The person making $150k is a very good businessman who owns the clinic. Everything else falls in between.

Yes if the hospital is paying thier CEO $3mil plus hookers then you have a complaint, but rural health care is one of the hardest places to make money. I sit in my office with the ability to throw a rock and hit 3 CT machines. I work with an insured affluent population. The people that do this don't just do it for the money and they have my respect.

David Carpenter, PA-C

cgfnp · Mar 20, 2007

I am somewhat confused. In your previous post you seem to imply that you are an NP student. Here you state that you work in a rural clinic. Which is it? Just because you interpret the situation in your town don't assume that it applies everywhere. In Eastern Colorado the medicaid/no insurance rate is truly staggering. Billing isn't going to be much here. If you look at the average income for PA's in rural FP the range is $1 to $150k. The person that is making $1 is a retired Navy Commander that pays herself a token dollar. The person making $150k is a very good businessman who owns the clinic. Everything else falls in between.
Yes if the hospital is paying thier CEO $3mil plus hookers then you have a complaint, but rural health care is one of the hardest places to make money. I sit in my office with the ability to throw a rock and hit 3 CT machines. I work with an insured affluent population. The people that do this don't just do it for the money and they have my respect.
David Carpenter, PA-C

I don't know where you got that I was a student. I work in a rural hospital as I said. And the Critical Access Hospital program is nation wide. Those small hospitals who choose not to participate probably are struggling. I've worked at small rural hospitals before and after converting and so far, 100% have been scraping by before converting and 100% have been financially comfortable after. This is "interpretation" in more than one hospital in more than one state.

I take it your last sentence implies that I am advocating or am personally doing this just for the money. This is the conclusion that's jumped to every time someone other than a MD/DO in healthcare mentions money, and it's crazy. Just because I want to get paid fairly means I don't care about anyone and I'd let someone die if it billed out more. I think the implication that money is such as bad word in healthcare is one of the reasons NPs and PAs get the shaft so often. Good example: go look at 10 MD ads and 10 NP/PA ads. I bet you'll see money mentioned 2-3X more in MD ads. Why aren't they being burnt at the stake?

core0 · Mar 20, 2007

I don't know where you got that I was a student. I work in a rural hospital as I said. And the Critical Access Hospital program is nation wide. Those small hospitals who choose not to participate probably are struggling. I've worked at small rural hospitals before and after converting and so far, 100% have been scraping by before converting and 100% have been financially comfortable after. This is "interpretation" in more than one hospital in more than one state.
I take it your last sentence implies that I am advocating or am personally doing this just for the money. This is the conclusion that's jumped to every time someone other than a MD/DO in healthcare mentions money, and it's crazy. Just because I want to get paid fairly means I don't care about anyone and I'd let someone die if it billed out more. I think the implication that money is such as bad word in healthcare is one of the reasons NPs and PAs get the shaft so often. Good example: go look at 10 MD ads and 10 NP/PA ads. I bet you'll see money mentioned 2-3X more in MD ads. Why aren't they being burnt at the stake?

And yes, I felt like getting out of the healthcare field every day of my terrible NP program. But then, I'd look over at my buddy who felt the same way and we'd laugh and start playing cards or reading medical journals and that kept us going.

This is what I was looking at. I may have misunderstood this.

The action you are seeing here is supply and demand. There is a dearth of MD's willing to work in rural areas and they have significantly more debt than NPP's. This is the reason that they demand about double the salary of an NPP. The gap closes some with experience, but remains about 2x that. Remember that they can get along without you in the hospital, they cannot get along without a physician.

I don't follow MD ads and I don't think that you can look at Locums jobs and get a sense of what a real salary is. The average salary for a FNP is about $152K Remembering that MD's get 15% more than NPP's for the same work. Average new grad salary is about $110-120k for FP. Some FP's can justify high salaries if they do Obstetrics (and pay the malpractice).

Here are a couple of articles on compensation:

http://www.annfammed.org/cgi/content/full/3/1/89

http://www.hschange.com/CONTENT/725/

Yes there are locums contracts that offer that large amounts of money, but this is desperation since if you do not have an MD your rural clinic or Critical access hospital ceases to function. You will see similar things for HSPA clinics for NP or PA's since you need one or the other to run the clinic.

The average salary for new grad PA's in FP was $65k. $57k is between the 25th and 10th percentile. For a PA that would be low and I would be hesitant to take it but you also have to remember this is a negotiation. As far as salary equality, do you think a new grad NPP is operating at the same level as a new FP MD? There is a reason that they get paid more, its called medical school. Every study that I am aware of shows that MD's bill out more than NPP and get slightly more than NPP's in a compensation to production ratio.

From MGMA 2004

Compensation /Production = ratio

PA NP FP MD

.24 .27 .33

Not twice, but not insignificant.

If you were offering $57k for a specialty practice I would tell them to take a walk. For new grad FP in a rural area, $57k is a reasonable starting point for negotiation. If you are talking about an experienced FP NPP then you would be talking about mid 70's. Bottom line there is a fixed pot of money that can go for salaries. If you want to try to take some of that from the MD's go ahead. If you want to open your own clinic go ahead, but I think that you will find this a real learning experience.

David Carpenter, PA-C

cgfnp · Mar 20, 2007

This is what I was looking at. I may have misunderstood this.

"I felt..." past tense. Just a misunderstanding as you said.

The action you are seeing here is supply and demand. There is a dearth of MD's willing to work in rural areas and they have significantly more debt than NPP's. This is the reason that they demand about double the salary of an NPP. The gap closes some with experience, but remains about 2x that. Remember that they can get along without you in the hospital, they cannot get along without a physician.

A dearth of MDs? Now that's a new one. Tell that to the administrator here. There sure aren't any beating down our doors.

I don't follow MD ads and I don't think that you can look at Locums jobs and get a sense of what a real salary is. The average salary for a FNP is about $152K Remembering that MD's get 15% more than NPP's for the same work. Average new grad salary is about $110-120k for FP. Some FP's can justify high salaries if they do Obstetrics (and pay the malpractice).
Here are a couple of articles on compensation:
http://www.annfammed.org/cgi/content/full/3/1/89
http://www.hschange.com/CONTENT/725/

I agree that locums isn't the same as regular salary. I don't think you'll find anyone smarter than a cinder block arguing that. But I'm not even talking about locum because that would not be pertinent. I'd look like an idiot trying to argue permanent salary against locum salary. I'm not even talking dollar amounts. Just compare the ones who even mention money. You'll find 1-2 out of 10 for NP/PAs and 7-8 out of 10 MD/DO. This is just supporting my argument that for anyone other than a MD/DO in heathcare to mention money is a mortal sin.

I don't follow MD ads, but I don't ignore them either, because it is pertinent to us in regards to family practice. As you said they get 15% more reimbursement, so why isn't our salary closer to 85% theirs? You mentioned productivity differences, which is understandable. But, with a productivity clause in your contract, you can negate that if you bust your *** and see the patients you need.

Yes there are locums contracts that offer that large amounts of money, but this is desperation since if you do not have an MD your rural clinic or Critical access hospital ceases to function. You will see similar things for HSPA clinics for NP or PA's since you need one or the other to run the clinic.

Wait, I thought there was a dearth of MDs willing to go rural. Why would anyone be desparate?

The average salary for new grad PA's in FP was $65k. $57k is between the 25th and 10th percentile. For a PA that would be low and I would be hesitant to take it but you also have to remember this is a negotiation. As far as salary equality, do you think a new grad NPP is operating at the same level as a new FP MD? There is a reason that they get paid more, its called medical school. Every study that I am aware of shows that MD's bill out more than NPP and get slightly more than NPP's in a compensation to production ratio.

This is a negotiation? Oh. I wasn't aware of that when I was trying to tell her how to negotiate to make good of that offer. And, I didn't know med school was longer and harder than NP/PA school. Oh, wait, I did say that earlier too. There is a difference, but studies show the averages. If someone regardless of their ability has a productivity clause, it will protect the smart and efficient ones from getting the shaft when they out do all the others. If someone is dumb or lazy and can't do it, then they won't be affected at all by the productivity clause.

If you were offering $57k for a specialty practice I would tell them to take a walk. For new grad FP in a rural area, $57k is a reasonable starting point for negotiation. If you are talking about an experienced FP NPP then you would be talking about mid 70's. Bottom line there is a fixed pot of money that can go for salaries. If you want to try to take some of that from the MD's go ahead. If you want to open your own clinic go ahead, but I think that you will find this a real learning experience.

Yes, I will learn that opening my own clinic isn't easy, and isn't without risk. But if you have the gonads it's one of the only ways to get paid fairly. This attitude that you are taking something from MDs or we are fighting over patients is rediculous. There are plenty of patients to go around. If you don't think so, just ask an ER doc and see how many ED visits could've been handled in the PCP office if they could get in within 2 weeks. That attitude is one of the reasons the AMA is fighting legislation that gives NP/PAs more practice rights because they have the same ideas in their minds of a silly turf war.