Why The Future of NP Practice Maybe A Two Edged Sword

[All4NursingRN]

I was recently speaking with another master's prepared nurse who works in informatics about becoming an Acute Care NP and my experience as an NP student. Her immediate response was "why would you want to do exactly what the physician does for a dramatically reduced salary"? At first I was offended and was really peeved that a nurse would be so unsupportive of advanced practice nursing and gave her the long winded "why advanced practice nursing is awesome speech" but after a few days I gave thought to what she said.

In my area (NYC metro) NPs start as low as high $90k (RN start out at the same salary) and may hit maybe $160k at the top of the range, with a few outliers here and there. As a student I have witnessed how much work the acute care NP may contribute to a medical service and have seen the MD being the ''overseer'' on some units with the NP & PA managing quite sick patients and responsible for many emergent procedures such as intubation, central line placements.... Although I love the thought of being so involved in patient care I have wondered if NPs (specifically acute care) will be compensated more by facilities for our ever increasing scope of practice? I was surprised to see some services where the so called "midlevels" entirely manage extremely sick patients and the attending only appears when the patient is deteriorating.

I was also at a conference recently where some rural and highly experienced NPs stated that at times they were the only provider in a hospital overnight with maybe an ER doc, or that they managed emergencies on their own or as part of a team of NPs.

I'm wondering if this is part of a whole push by hospital executives to use advanced practice nurses as cheaper medical provider for cost savings.

This has dramatically altered my outlook as a soon to be graduate. I question if I want to be a ''forever resident'' performing all the scut work on the unit while only being payed a small fraction of what the attending (who seem to have the last say in regards to patient management) makes.

Acute care NPs diagnosing, managing, and running emergencies, also having to have the knowledge of a full fledged physician to only make 30-40% of what the attending makes sounds a bit troublesome to me. I still love the nursing profession, it's been my career home for 15 years but I do wonder if this is setting up to be a catch 22 with the corporate hospital system reaping massive benefits off of cheaper labor?

With the push for more autonomy and scope, will our salaries commensurate?

Just me theory.... what do you think?

[Corey Narry, MSN, RN, NP]

From my perspective and experience, I don't really see myself as underpaid compared to the attending. It's true that we all work in the ICU and do the same types of stuff in terms of management and procedures. Aside from my billing being assessed 85% of what the attending would have billed for, I see the attending working harder. I work 36 hours a week and is paid by the hour. The attending works up to 10 hours a day everyday 7 days a week and is salaried. His or her responsibilities are greater than mine because I would escalate complex situations to him or her since the rule is that all hospitalized patient's must have an attending physician on record.

[Hoosier_RN, MSN]

9 hours ago, juan de la cruz said:

From my perspective and experience, I don't really see myself as underpaid compared to the attending. It's true that we all work in the ICU and do the same types of stuff in terms of management and procedures. Aside from my billing being assessed 85% of what the attending would have billed for, I see the attending working harder. I work 36 hours a week and is paid by the hour. The attending works up to 10 hours a day everyday 7 days a week and is salaried. His or her responsibilities are greater than mine because I would escalate complex situations to him or her since the rule is that all hospitalized patient's must have an attending physician on record.

But, some areas are talking of doing away with the attendings and going to all NP settings. Not just MD offices. But no increase in pay. I've read these concerns and could definitely see it happening due to the corporate greed of hospitals and their shareholders. In fact, talking to some of my NP friends, we could envision seeing this in our lifetime. While the care would still be good, the billing would be the same, practitioners would make less than the MD counterparts. I nightmared about this years ago when starting my MSN. One reason that I didn't do the NP route

[Corey Narry, MSN, RN, NP]

Yes, corporate interests will favor physicians because the private practice model is still prevalent in US hospitals. In this model, private physician groups seek hospital privileges and bill for their own services. The hospitals benefit financially from this model when physicians admit their patients and do procedure and surgeries in the hospital.

NP's don't perform high revenue surgical and interventional procedures. Aside from operational cost related to physician "enticements" such as doctor's lounges, fancy OR suites, prime parking spots, etc., there isn't revenue loss from having physicians on staff in fact they have long been considered revenue earners.

In terms of physician pay, you have to factor in the high financial cost and time commitment required to become a fully trained physician. Average indebtedness is high after med school. You're not going to attract a pool of smart medical students if return of investment after their long and expensive training won't pay off in the end.

I know there are some places where NP's and PA's are the sole providers especially in rural communities where Critical Access Hospitals can be found. That's a consequence of supply and demand. Some of these places have a tough time attracting physicians. I think these providers are the heroes for stepping up and must be compensated better and/or receive additional perks for staying there.

Having said all of this, I agree that NP and physician pay parity is worth looking into regardless and there have been previous posts that addressed it. However, I would say the disparity is more glaring between Anesthesiologists and CRNA' who do exactly the same work.

[murseman24, MSN, CRNA]

On 1/24/2020 at 1:40 PM, juan de la cruz said:

Having said all of this, I agree that NP and physician pay parity is worth looking into regardless and there have been previous posts that addressed it. However, I would say the disparity is more glaring between Anesthesiologists and CRNA' who do exactly the same work.

*slow hand clap* The first accredited school of anesthesia in the US was taught by a nurse anesthetist (students were nurses, dentists, physicians). Nurse anesthetists were the original anesthesia providers.

[Tegridy]

On 1/23/2020 at 8:55 PM, All4NursingRN said:

I was recently speaking with another master's prepared nurse who works in informatics about becoming an Acute Care NP and my experience as an NP student. Her immediate response was "why would you want to do exactly what the physician does for a dramatically reduced salary"? At first I was offended and was really peeved that a nurse would be so unsupportive of advanced practice nursing and gave her the long winded "why advanced practice nursing is awesome speech" but after a few days I gave thought to what she said.

In my area (NYC metro) NPs start as low as high $90k (RN start out at the same salary) and may hit maybe $160k at the top of the range, with a few outliers here and there. As a student I have witnessed how much work the acute care NP may contribute to a medical service and have seen the MD being the ''overseer'' on some units with the NP & PA managing quite sick patients and responsible for many emergent procedures such as intubation, central line placements.... Although I love the thought of being so involved in patient care I have wondered if NPs (specifically acute care) will be compensated more by facilities for our ever increasing scope of practice? I was surprised to see some services where the so called "midlevels" entirely manage extremely sick patients and the attending only appears when the patient is deteriorating.

I was also at a conference recently where some rural and highly experienced NPs stated that at times they were the only provider in a hospital overnight with maybe an ER doc, or that they managed emergencies on their own or as part of a team of NPs.

I'm wondering if this is part of a whole push by hospital executives to use advanced practice nurses as cheaper medical provider for cost savings.

This has dramatically altered my outlook as a soon to be graduate. I question if I want to be a ''forever resident'' performing all the scut work on the unit while only being payed a small fraction of what the attending (who seem to have the last say in regards to patient management) makes.

Acute care NPs diagnosing, managing, and running emergencies, also having to have the knowledge of a full fledged physician to only make 30-40% of what the attending makes sounds a bit troublesome to me. I still love the nursing profession, it's been my career home for 15 years but I do wonder if this is setting up to be a catch 22 with the corporate hospital system reaping massive benefits off of cheaper labor?

With the push for more autonomy and scope, will our salaries commensurate?

Just me theory.... what do you think?

I think nurse practitioners don’t have the same level of knowledge of physicians to start

[Thanksforthedonuts, MSN, APRN]

NPs don’t have the same education or training as physicians, therefore the pay reflects that. The responsibility is similarly high, yes, but unfortunately we don’t get paid solely based off our responsibilities. I can’t imagine how one can compare the education of an NP with a MD and say we are equal, we are not. NPs have their place in the care team. We have an advanced and well organized healthcare system in the US where nurses can become NPs and safely navigate within their trained track.
I personally find it embarrassing when NPs says, “I’m the Doctor” .... ehhhh no you’re not. Though in certain tracks we perform many similar duties, the knowledge base is profoundly different.

In a true emergency I want a MD, for routine care I see a NP.

[babyNP., APRN]

A couple of things- pay is region dependent. Wages are depressed in nyc and other major cities in the northeast due to supply and demand. A lot of people want to live there and therefore hospitals have an upper hand. When I was a new grad I got paid $95k in the southwest and the going rent for a nice apartment was about $1100...

I think that doctors should get paid more due to their specialization and more clinical/education hours. Yes it’s the same job but it’s the same reason why you pay a plumber more $$ than a handyman.

[myoglobin, ASN, BSN, MSN]

The answer to this by and large is move to an IP state and have your own practice and groups. At the same time we should out lobby physicians in states that are not IP to gain that status. Thus, in states like Washington, Arizona, Oregon, and elsewhere it is possible to practice with full autonomy and bill directly to insurance companies. Indeed, the insurance rates are often so much better that 85% percent in say Seattle is probably better than 100% in Alabama, Florida, or South Carolina. Every study so far suggests that in spite of our educational disparities NP's have equal or superior outcomes in essentially every area measured. What's more (and most importantly) the public often prefer NP's.

[Tegridy]

1 hour ago, myoglobin said:

The answer to this by and large is move to an IP state and have your own practice and groups. At the same time we should out lobby physicians in states that are not IP to gain that status. Thus, in states like Washington, Arizona, Oregon, and elsewhere it is possible to practice with full autonomy and bill directly to insurance companies. Indeed, the insurance rates are often so much better that 85% percent in say Seattle is probably better than 100% in Alabama, Florida, or South Carolina. Every study so far suggests that in spite of our educational disparities NP's have equal or superior outcomes in essentially every area measured. What's more (and most importantly) the public often prefer NP's.

You mean similar out comes for routine uncomplicated primary care. Aka run of the mill stuff that anyone could follow a guideline for. Most people still prefer physicians

You make it sound as if 17 months of writing papers And clinical hours is superior to a rigorous 7 year medicals education and residency

[ghillbert, MSN, NP]

12 hours ago, Thanksforthedonuts said:

In a true emergency I want a MD, for routine care I see a NP.

Eh, depends - if I arrested, I'd rather be taken care of by a critical care/ER NP than a dermatology or GI MD.

[Thanksforthedonuts, MSN, APRN]

2 hours ago, ghillbert said:

Eh, depends - if I arrested, I'd rather be taken care of by a critical care/ER NP than a dermatology or GI MD.

Obviously. If I have a cold do I go to a primary care provider or a veterinarian? If I’m in labor to I see a Derm or an OB?

Forgive me, but that’s a petty comparison.