Why do psych NPs make more?

Specialties NP

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I just got hired per diem at a substance abuse treatment facility as an FNP (2 yrs experience). A friend of mine is a psych NP who just graduated this past Summer, got hired at the same facility around the same time. She makes substantially more than me. I knew this going into my interview and negotiated, but was turned down, and told that "psych NPs always make more." I took the job anyway because I love it, but honestly (and please NO offense intended) don't get the salary discrepency. 

I carry a load of 25 - 30 patients, she has 8-10. I prescribe everything from htn meds, insulin, suboxone,  and she only prescribes the mental health meds. I do physical assessments, she does not.

Is this difference in pay typical? Again, without sounding like an ignorant buffoon... why?

Specializes in Psychiatry.
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. 

MentalKlarity said:

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. 

Not psych. That’s why I’m asking the question. But also curious based on how patient visits are set up. In primary care, most of us are seeing 15-20 in appointments. Many people do charges for time. While newer roles allow it, I generally question the “honest” times most clinicians spend with their patients. Though your explanation checks out. Thank you. 

Specializes in Psychiatry.
djmatte said:

Not psych. That's why I'm asking the question. But also curious based on how patient visits are set up. In primary care, most of us are seeing 15-20 in appointments. Many people do charges for time. While newer roles allow it, I generally question the "honest" times most clinicians spend with their patients. Though your explanation checks out. Thank you. 

Most psych providers do 30-60 min appts. It is beneficial for the patient (less rushed appt), the provider (more time with patient, for charting, etc), and for the employer (can code for the therapy add ons to bill for higher). I see 8-12 per day total.

Specializes in oncology.
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. 

How did I know you would come in this thread boasting your Practice with you and your subordinates that will provide you a lifetime of  income, with you delegating the practice to your subordinates doing the work .

ZyzzFan said:

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

Recommending something that is not necessary 'makes my skin crawl' 

selll devil.jpg
Specializes in DNP, PMHNP, FNP-C.
londonflo said:

How did I know you would come in this thread boasting your Practice with you and your subordinates that will provide you a lifetime of  income, with you delegating the practice to your subordinates doing the work .

Recommending something that is not necessary 'makes my skin crawl' 

selll devil.jpg

I do plenty of work and don't refer to employees as "subordinates".

As for Suboxone it has its uses.  I'd rather someone be on Suboxone for a period while they get their mind right and taper off compared to possibly buying something tainted with fentanyl off the street.

Specializes in oncology.
ZyzzFan said:

As for Suboxone it has its uses.  I'd rather someone be on Suboxone for a period while they get their mind right and taper off compared to possibly buying something tainted with fentanyl off the street.

https://twintowntreatmentcenters.com/is-suboxone-a-wonder-drug-that-helps-heroin-addicts-get-clean-or-just-another-way-to-stay-high/

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Suboxone is "not being used in the context we've seen it to kick a habit or even to replace a narcotic dependence. It's just a way to control your habit a little bit better.”

"

Quote

Brennan doesn't seem surprised, or especially concerned, to learn that people are using Craigslist to sell their detox meds. She notes that Craigslist drug sales have transpired on and off for years. "Our focus is on more of the major suppliers,” she says. "But we do monitor Craigslist, and we do periodic sweeps there.

Quote

"It's not being used in the context we've seen it to kick a habit or even to replace a narcotic dependence,” she asserts. "What I've seen is not a real commitment to getting clean, it's just a way to control your habit a little bit better.”

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Like other opiates, buprenorphine binds to certain receptors in the brain. It's "stickier" than drugs like heroin, binding to those receptors faster and holding on longer: Morphine has a half-life of about two hours; buprenorphine's is anywhere from 24 to 60 hours.

 

Specializes in DNP, PMHNP, FNP-C.
londonflo said:

That isn't a legitimate source and the author "Anna Merlan" on Google only comes up as a "Journalist" for the Alt-Left publication "VICE".  Is that the same author?  You would be hard pressed to find a "source" worse than something written by a person associated with VICE.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585403/

"Since its discovery in 1966 and the initial proposal for its use as a treatment for opioid use disorder in 1975, buprenorphine has been shown to be effective for treatment of pain and medically-supervised withdrawal or maintenance treatment of opioid use disorder. It is now widely used worldwide for treatment of opioid use disorder, although most patients with opioid use disorder are still not receiving effective medication treatment, and more effort is needed to disseminate buprenorphine therapy across health systems. Numerous studies and meta-analyses have concluded that buprenorphine-at sufficient doses-is safe, improves treatment retention, and decreases illicit opioid use. In addition to its activity on the mu-opioid receptor, buprenorphine may also have therapeutic effects on mood through antagonism of the kappa opioid receptor. Although generally safe, there remains a risk of diversion, sedation, and overdose, especially when combined with other substances. Newer, long-acting parenteral formulations of buprenorphine, mainly the long-acting injections, have the potential to improve adherence and thus expand on the effectiveness and dissemination of buprenorphine."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741113/

"Although psychosocial treatments are effective in opioid dependence,76 opioid maintenance treatment is a well-established first-line approach16,87 and is recommended by numerous treatment guidelines.17,25-28 Patients out of treatment have a much higher mortality rate than those in maintenance treatment."

 

I don't personally prescribe these medications anymore as standard medication follow ups are just as lucrative financially however, they definitely have their place.  I am not saying there aren't a ton of sketchy Suboxone/Methadone clinics out there getting rich off of people's addictions but that doesn't take away from its use when prescribed appropriately.  

Specializes in oncology.
ZyzzFan said:

don't personally prescribe these medications anymore as standard medication follow ups are just as lucrative financially however, they definitely have their place. 

Lucrative meaning:  Producing a sizeable profit.

Synonyms: moneymaking, remunerative, profitable

Noun: lucrativeness

Lucrativeness meaning: The quality of affording gain, benefit or profit

Synonyms: gainfulness, profitability, profitableness

I don't read anything here about helping humanity. 

 

 

 

lucrative.jpg
Specializes in DNP, PMHNP, FNP-C.
londonflo said:

Lucrative meaning:  Producing a sizeable profit.

Synonyms: moneymaking, remunerative, profitable

Noun: lucrativeness

Lucrativeness meaning: The quality of affording gain, benefit or profit

Synonyms: gainfulness, profitability, profitableness

I don't read anything here about helping humanity. 

 

 

 

lucrative.jpg

Isn't that the point of business?

Specializes in oncology.
ZyzzFan said:

I am not saying there aren't a ton of sketchy Suboxone/Methadone clinics out there getting rich off of people's addictions but that doesn't take away from its use when prescribed appropriately.  

You are looking sketchy too. 

Wow, its sad how many people think its all supply and demand. It's the same reason a general practice MD will not make as much as a Psychiatrist. Psych Nps are specialist. FNPs are not! The brain is the most complex organ. So much so that we rely a lot on theory still for treatment. No offense to FNPs, but I can always tell when a new patient comes to me and has had psych meds from their PCP. They are being given Effexor and a hypertensive med, they have a history of an eating disorder and are on wellbutrin, they are on Vyvanse but don't know to take it on an empty stomach due to the attached lipase, they take antipsychotics at the same time as PPI. Or they come from a psych provider to their pcp and are taken off meds because they are told the med isn't used to treat the symptom. I had a patient who came to me asking to be put back on her propranolol for her anxiety, because he FNP said that's not what its for. It's not only prescribed for anxiety its been shown in clinical trials to be as effective as benzos.

 

s franklin said:

Wow, its sad how many people think its all supply and demand. It's the same reason a general practice MD will not make as much as a Psychiatrist. Psych Nps are specialist. FNPs are not! The brain is the most complex organ. So much so that we rely a lot on theory still for treatment. No offense to FNPs, but I can always tell when a new patient comes to me and has had psych meds from their PCP. They are being given Effexor and a hypertensive med, they have a history of an eating disorder and are on wellbutrin, they are on Vyvanse but don't know to take it on an empty stomach due to the attached lipase, they take antipsychotics at the same time as PPI. Or they come from a psych provider to their pcp and are taken off meds because they are told the med isn't used to treat the symptom. I had a patient who came to me asking to be put back on her propranolol for her anxiety, because he FNP said that's not what its for. It's not only prescribed for anxiety its been shown in clinical trials to be as effective as benzos.

 

Family medicine is a specialty. Much like FNPs. It requires its own board certifications in its own right. So let's not argue over who commands more in what capacity. A psych NP isn't any more qualified to treat hypertension than a psychiatrist.  The only reason psych NPs are paid more is because the overhead is less. They are still reimbursed at the same rate for an office visit as any other medical provider. They don't have the "luxury" of an MA or office equipment needed to run a clinic. There's essentially more flexibility in the value of RVUs. 

Your  anecdote doesn't speak for all PCPs and your superiority complex is perplexing as many of those in family health are simply trying to keep up with the demand because of lack of mental health access.  Most of the medications we have access to are old and we don't have the time to go through the complex prior auths to get them on newer medications while we address 5 other problems.  As you treat the "most complex" organ, you're dismissive to those have to deal with every other organ system, chronic pain, diabetes management, hyperlipemia, and by the way ensure all of our HEDIS measures are up to date.

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