Why do psych NPs make more?

It's mostly supply and demand. Psych has always been an unpopular specialty in the nursing and medical fields, and not many people want to do it even though the demand is there.

I do believe things will change in the coming years. I've seen some obvious changes in my area's PMHNP job market over the past 2-3 years. People are aware that PMHNPs get paid more and there's been a large increase in supply.

Specialty usually pays more than primary care (this is true for physicians and PAs too), and supply vs demand.

While I do think we are seeing a shift towards having more psychiatric providers (both NPs and MDs) it will take some time before wages fall (though I do think they will fall in time).

Substance use is it's own sub-specialty with in psych, and finding psychiatric providers who can manage the substance use + mental health aspects can be challenging.

As noted, supply and demand. Not to mention pure numbers that you can turn over. When patients come to psych, they’ve often had the physiological reasons for their symptoms ruled out. You aren’t spending 15 to 30 minutes assessing the ailments that accompany their mental health issues.  Top that with the simple fact most psych nps are not actually doing psycho therapy. Their goal is typically medication management. You can see a lot more patients than your average primary care clinic. 

On 10/11/2020 at 2:53 PM, djmatte said:

As noted, supply and demand. Not to mention pure numbers that you can turn over. When patients come to psych, they’ve often had the physiological reasons for their symptoms ruled out. You aren’t spending 15 to 30 minutes assessing the ailments that accompany their mental health issues.  Top that with the simple fact most psych nps are not actually doing psycho therapy. Their goal is typically medication management. You can see a lot more patients than your average primary care clinic. 

I'm not sure that "seeing more patients" is true. I only see a max of two patient's per hour and take 90 minutes for intakes and make more than double what I would earn as an FNP in Florida.

Simple: the psych NP is trained and well versed in everything psych, and you as an FNP are not.

Yes, you are prescribing suboxone, but the psych NP is probably doing the same, plus psych med mgmt, plus initial evaluations, which can easily take 60-90 minutes. Her higher level of expertise in psych over your limited expertise by virtue of your family medicine education means she deserves to be compensated more than you.

I work in psych as an FNP and understand this clearly. I see all follow up appts doing med mgmt, like my fellow psych NP colleague, but I do not do initial evals as this is rightfully reserved for the psych NP with training.

I know of a few people going back to get psych certifications.  Well-said already, supply and demand, and in a few years should settle back down. Now, if the business of NP schools would take note!  LOL they already have references like law school, where a graduating attorney can feel lucky to land a paralegal position to "get in the door."  Anyway, I digress...

.

I believe that much of the pay disparity results not only from supply and demand but also insurance reimbursement. Thus, I use complexity based coding which means I get to charge not only for the 30 min medication management visit, but also the 16 minutes of supportive therapy (for example 99214 and 90833) with even Medicare this reimburses about $180 per 30 min or $360 per hour. When your company is earning $300 per hour on your work it is not unreasonable for them to be paying you $150.00 plus per hour. Also, the social stigma of using mental health services has diminished such that instead of 5 percent of the population using these services in areas like Seattle where I practice maybe 20 percent do. Also, as FNP displace MD's in areas of the country like Washington and Oregon many of these are even less willing to write for psych meds than MD's creating even more demand. Also, political turmoil and Covid while harmful to psychological well being is good for the psych business. Also many people come to me because their psychiatrist or their NP does not make much use of CAM approaches such as SAMe for depression, standardized lavender extract for anxiety or even Saint John's Wort for mild depression. To say nothing of the yoga, strength training, light therapy and dietary approaches that I integrate. Thus even as a first year graduate I have a three month waiting list to be seen. If business ever gets tight I will continue to add licenses to the Arizona, Colorado, and Washington that I already hold to expand reach and possibly expand in to places like Nevada and offer "late evening/weekend" appointments.

@myoglobin is it tough on your own mental health to deal with psych patients? I’m worried I’ll hear things too disturbing for me to ever get out of my head. I’d love to help these patients as I 100% believe you can’t have good overall health without solid mental health, I’m just worried I won’t be able to handle it. Thank you! 

ZyzzFan said:

Supply and demand as well as the money they bring into the practice.  I bill around at least $300/hour doing 2x 99214+90833.  

Regarding the Suboxone even if you are an FNP you can bring in some good money prescribing that.  You should be able to get $150/RX x100 or 30 depends on your waiver per month if you negotiate well

 

How do you charge for both?  What do your appointment times look like?  Sounds borderline fraudulent. 

djmatte said:

How do you charge for both?  What do your appointment times look like?  Sounds borderline fraudulent. 

Are you kidding? Do you do psych? 

99214 is a complexity code. In psych it applies to 90% + of patients. Having a prescription + 2 diagnoses that are stable (MDD and GAD with lexapro for example) is automatically a 99214 even if the appt is med management for 5 mins. That is literally how the code is met. 99213 is reserved for one diagnosis stable - usually ADHD with a medication refill, stable. 99215 is much more complex - managing lithium levels or an actively suicidal patient. You can bill all of these based on "time' but in psych it is easier to meet complexity. 

90833 is "30 mins therapy" but in practice it covers any amount of therapy from 16-37 minutes per coding rules.  

So again, 99214 + 90833 is very, very common in psych and it means "moderately complex client with 16 mins therapy." For a 30 min appt this could mean 5-10 mins of medication management for someone on an SSRI with MDD and GAD followed by 20 mins of discussing of coping skills/anxiety management/guided meditation/sleep hygiene, etc.