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?

[myoglobin, ASN, BSN, MSN]

In my case that was four years after working as an RN for eight years when I started the program. No, I’m not saying that the educational is superior only that the outcome studies (mostly in primary care) have shown equal or better outcomes for NP’s. One hypothesis to explain this is that more extensive education doesn’t always translate to better results. All I can say is that I’ve spoken to many NP’s in IP states (mostly in Psych or FNP or geriatrics) earning upwards of 200k and in more than a few cases 300k by working in groups with other NP’s where they receive around 70 percent of insurance revenues received. Also some have started companies with multiple locations earning many times this amount (granted by employing others). There is a robust demand for NP services in states that facilitate IP.

[Thanksforthedonuts, BSN, RN]

I don’t want to stir up a can of worms... but should LPNs and RNs or Medical assistants get paid cause they “like do they same thing”?
I know plenty of LPNs that can run circles around some RNs. But the scope and education is difference and, whether you want to admit it or not, being the higher educated one, you’ll see it either minutely or dramatically at times.

[myoglobin, ASN, BSN, MSN]

The bottom line is that NP’s are trained and licensed in about half the states to provide IP. Also that trend is growing with an aging population and high cost containment demands. And if you are going to practice as an NP should’ve you at least aspire to do it somewhere that you are likely to earn double the money and not have your livelihood dependent on someone (a doctor) who might believe as you seem to that our educations are inferior?

[Thanksforthedonuts, BSN, RN]

4 minutes ago, myoglobin said:

In my case that was four years after working as an RN for eight years when I started the program. No, I’m not saying that the educational is superior only that the outcome studies (mostly in primary care) have shown equal or better outcomes for NP’s. One hypothesis to explain this is that more extensive education doesn’t always translate to better results. All I can say is that I’ve spoken to many NP’s in IP states (mostly in Psych or FNP or geriatrics) earning upwards of 200k and in more than a few cases 300k by working in groups with other NP’s where they receive around 70 percent of insurance revenues received. Also some have started companies with multiple locations earning many times this amount (granted by employing others). There is a robust demand for NP services in states that facilitate IP.

This is very true. I’m in Seattle area (Eastside) too Myoglobin. It appears that this business approach would be the best bang for your buck if money is their primary gripe. There are quite a few NP practices in our area that provide visiting PCP services for seniors in assisted living and adult family homes. There is a huge demand for their services!

[Kooky Korky, BSN, RN]

Go to Medical School if you want the pay, prestige, and standing of a doctor.

I understand how you feel, but being a nurse, advanced or not, will likely, as far as I can see, be different than being a doctor.

I know the truth of how much a great nurse is worth, you know, even some doctors see it. But the general public? I don't think so.

It's like being a corporate exec or business owner vs. the assembly line workers or the admin assistant. The bosses would be lost without the "lower" level workers. We know that a great AA is worth his or her weight in gold, but the public might not understand or realize that.

Best wishes to you as you make your choices.

[murseman24, MSN, CRNA]

13 minutes ago, Kooky Korky said:

We know that a great AA is worth his or her weight in gold, but the public might not understand or realize that.

A what?

[myoglobin, ASN, BSN, MSN]

35 minutes ago, Kooky Korky said:

Go to Medical School if you want the pay, prestige, and standing of a doctor.

I understand how you feel, but being a nurse, advanced or not, will likely, as far as I can see, be different than being a doctor.

I know the truth of how much a great nurse is worth, you know, even some doctors see it. But the general public? I don't think so.

It's like being a corporate exec or business owner vs. the assembly line workers or the admin assistant. The bosses would be lost without the "lower" level workers. We know that a great AA is worth his or her weight in gold, but the public might not understand or realize that.

Best wishes to you as you make your choices.

No one is calling for the "same" prestige or even pay as MD's. However, consider two situations.

1. PMHNP works for MD in Florida and has to see about four patients per hour billed at about $100.00 per appointment (give or take) for which the company get reimbursed at 80% (or 100% in the 30% who are private pay). It is an assembly line of patients and the NP often works several hours late, with no lunch while the patients often wait hours for their appointment (do to appointments running over).The NP earns a salary of about 120K with minimal benefits. There job is completely dependent upon an MD who provides "in name only" oversight. In most cases they know little to nothing about the patient, their condition or situation.

2. PHHNP in Washington or Arizona has the flexibility to have 30minute appointments (again we are talking medical management). For which they are compensated 70% (in some cases they also may a monthly office fee of around $500) and they earn on average around $100.00 per hour. They are completely autonomous and have the ability to do essentially anything that a Psychiatrist would do.

Why as an NP would I choose to do twice the work for nearly half the pay? Wouldn't it be better to move to a state that allows me to have greater control over my pay and destiny while at the same time being able to spend nearly twice the time with the patient and the patients be able to get seen with a much shorter wait time?

[Corey Narry, MSN, RN, NP]

Early in our development as providers, NP's were being presented as a "cost-effective" alternative to physicians. I believe this is the reason for the 85% billing as opposed to the 100% that physicians get. I agree that the solution to the current pay disparity is to allow full independent practice in terms of primary care and out-patient Psych (or you can even count out-pt Women's Health in that).

This would allow NP's to set-up primary care practices without having to pay a physician for a "pretend" collaboration agreement or join a group with physicians who control the NP's salary. I would, however, say that 85% billing would still not be a bad deal especially if the NP is capturing all that revenue. In-patient is a different issue. Medicare requires that all hospitalized patients be under the care of an attending physician. There is no way acute care will change to independent practice unless that Medicare rule changes.

[Hoosier_RN, MSN]

19 hours ago, murseman24 said:

A what?

Administrative assistant--unit secretary or ward clerk. They do a big share of work, like CNAs and are underappreciated!

[myoglobin, ASN, BSN, MSN]

3 hours ago, juan de la cruz said:

Early in our development as providers, NP's were being presented as a "cost-effective" alternative to physicians. I believe this is the reason for the 85% billing as opposed to the 100% that physicians get. I agree that the solution to the current pay disparity is to allow full independent practice in terms of primary care and out-patient Psych (or you can even count out-pt Women's Health in that).

This would allow NP's to set-up primary care practices without having to pay a physician for a "pretend" collaboration agreement or join a group with physicians who control the NP's salary. I would, however, say that 85% billing would still not be a bad deal especially if the NP is capturing all that revenue. In-patient is a different issue. Medicare requires that all hospitalized patients be under the care of an attending physician. There is no way acute care will change to independent practice unless that Medicare rule changes.

I also believe that NP's can and do get better pay inpatient in independent practice states. Obviously, ARNP's will work as part of a "collaborative team" with physicians (who are uniquely equipped to do certain inpatient procedures), but having the independent licensure status still encourages better pay because they do not have to always show a collaborative physician to maintain their license (making them easier to employ for hospitals and increasing their ability to switch jobs for better opportunities). My point is that your solution already exists in about half the states. However, so many NP's continue to work in states without IP status and therefore fail to benefit from the better pay and benefits that it engenders. Also, most FNP's in IP states (and PMHNP's to a lessor extent) don't attempt to compete directly in primary care with physicians (although I have seen some PMHNP groups in Washington that employ physicians who work for them. I've also seen this with Psy D's who employ both PMHNP's and psychiatrists frankly I believe these "counselor" led/owned groups tend to provide the best care in psychiatry). There is no reasons that CRNA groups in IP's states couldn't compete directly with physician owned groups (again even if they employed some MD's on staff). They should have an intrinsic, cost "competitive advantage" that eventually gives them dominance over physicians in states that allow IP.

[Corey Narry, MSN, RN, NP]

Well hospitals are also governed by Medical Staff boards that are typically run by senior physician leadership with a CMO leading the pack. That's going to be a hurdle for NP's in some institutions to gain invitation to that exclusive club as an equal regardless of whether the state is NP independent practice or not. And even if NP's can break in with equal privileges, we're still going to have to circumvent the rule that a physician must be the primary attending as Medicare requires. I'm sure NP's are already acting as attendings in Critical Access Hospitals but I don't see that happening anytime soon on a large scale especiallyi inmetro areas where physicians have control of the market.

[myoglobin, ASN, BSN, MSN]

35 minutes ago, juan de la cruz said:

Well hospitals are also governed by Medical Staff boards that are typically run by senior physician leadership with a CMO leading the pack. That's going to be a hurdle for NP's in some institutions to gain invitation to that exclusive club as an equal regardless of whether the state is NP independent practice or not. And even if NP's can break in with equal privileges, we're still going to have to circumvent the rule that a physician must be the primary attending as Medicare requires. I'm sure NP's are already acting as attendings in Critical Access Hospitals but I don't see that happening anytime soon on a large scale especiallyi inmetro areas where physicians have control of the market.

What you are saying is no doubt true and would be more of an issue for CRNA only groups. However, even ARNP's in IP states that practice under physicians are in a significantly superior position because "their license is their own". Which is to say in Florida if I work as an ARNP at hospital "A" and want to switch to hospital "B" I must find a physician willing to act as my "collaborator" as part of the process. However, in an IP state like Washington if I switch from hospital "A" to hospital "B" there may still need to be a leading "attending" but he would not have to be a "collaborator" for the state as far as licensing goes. This leads to a better "market" for NP providers and generally higher pay.