How to get hospital to pay you (really pay you) to supervise nurse practitioners?

[nexus73]

It sounds like most hospitals, even in states with laws that allow np independent practice, will have bylaws requiring physician oversight of nps. I am not interested personally in supervising an np, unless I have time in my day to review notes and check in with each patient, and get paid significantly for taking on the work and risk, but I'd really prefer to not do it at all. It sounds like most hospitals in independent states will have physicians as supervisors on paper, but not require the psych MD to actually co sign notes or see the patient. And they might pay the MD anywhere from a few hundred up to a thousand dollars a month for this. Which is peanuts compared to what they're saving with an np over an MD. Has anyone had luck getting hospital to pay what this is truly worth? Which I'd argue is probably closer to $5000-8000 per month. Given the shortage of psychiatrists I assume many places the hospitals are not able to require supervision as part of the job, assuming the MD would just leave as an alternative.

---

Members don't see this ad.

 

[PikminOC]

I've seen 2500 a year which is peanuts

 

[Ludwig2000]

I've seen 2500 a year which is peanuts

With inflation like it is, you can’t even get good peanuts for 25 hundo a year

 

[calvnandhobbs68]

No. There tends to be old psychiatrists or psychiatrists who just don’t care or who don’t want to rock the boat who tend to agree to do these anyway. For instance, at one place I was at the department head would just agree to “collaborate” with the new NPs. There’s not a ton of leverage besides just refusing to do it.

I posted this in another thread but there are a lot of psychiatrists who view this as easy money, even at 1K a month. Line up 5 NPs and make an extra 60K/year. There are even “collaboration services” where they can pay some rando doc whos licensed in that state to “collaborate” with them as they go out to setup their own practice.

 

[Candidate2017]

Hospitals won't pay you more to "supervise" midlevels. Let's call it what it is: letting the hospital use your malpractice insurance, for a few thousand, so they can make more money.

Midlevels should be used as originally intended: handpicked by the physician, trained by the physician, and work for the physician to allow the physician to deliver care to more patients. Surgical practice groups tend to do this. Some old school psychiatrists do this and their midlevels function as permanent interns. They gather collateral such as records and med lists, preround, present, prepopulate the note, place med orders as directed, and triage issues when the psychiatrist goes to clinic or cover a second psych unit.

 

[J ROD]

My hospital has NP salary and MD wrvu based. So I use them to see more patients and make more money for myself. So I do not mind "supervising" them because they make me money. I expect this to change as they have already changed NP to wrvu based in other specialties.

 

[nexus73]

My hospital has NP salary and MD wrvu based. So I use them to see more patients and make more money for myself. So I do not mind "supervising" them because they make me money. I expect this to change as they have already changed NP to wrvu based in other specialties.

You get the RVUs generated by the nps?

 

[Stagg737]

Hospitals won't pay you more to "supervise" midlevels. Let's call it what it is: letting the hospital use your malpractice insurance, for a few thousand, so they can make more money.

Midlevels should be used as originally intended: handpicked by the physician, trained by the physician, and work for the physician to allow the physician to deliver care to more patients. Surgical practice groups tend to do this. Some old school psychiatrists do this and their midlevels function as permanent interns. They gather collateral such as records and med lists, preround, present, prepopulate the note, place med orders as directed, and triage issues when the psychiatrist goes to clinic or cover a second psych unit.

This. Only times I've heard of physicians being reimbursed well for supervising NPs is in PP, which is essentially the same as employing a physician you'd need to supervise. I have the same feelings of what "supervision" means as well. Mid-levels should function as residents who never graduate and can gain more independence in terms of supervision as you work with them and see they know what they're doing. I also wouldn't want to independently supervise anyone without being able to meet them and interview or talk extensively with them before they work under me. I don't want my license associated with anyone who thinks Nystatin is for cholesterol...

 

[comp1]

There's pretty good literature stating this doesn't actually increase malpractice exposure significantly, so I think hospitals consider this in terms of compensation. You'd have to present the hospital with alternative evidence to argue otherwise and...good luck, lots of people have tried on this board. So much is based on the quality of the specific NPs, as it can be variable, just like with MDs. If you want to make sure it has some tie to your actual workload, you can ask that it be tied to their RVUs. That doesn't make as much sense in a salaried position. In that case, you would want dedicated time blocked off each week for reviewing their charts and care provided.

 

[Sushirolls]

And this leads us to the corollary to this topic where things are heading:
*can't negotiate much of anything with Big Box Shops
*Big Box shops are going to continue the business of business and go with the cheapest labor they can. MD/DO will only serve as the token department heads with a sea of ARNPs under them.
*We see, and we know the negatives or ARNPs, but thus far their failings are 'within the cost of doing business' in the eyes of the Big Box Shops, remember Admins running these places aren't medical.
*Two tier care is going to emerge in the US. The states that don't have certificates of need for opening up hospitals will be ahead of the curve with opening up hospitals that don't take medicare or medicaid, and only insurance that plays ball with them.
*The US health landscape will start to look a bit more like what I've seen in some foreign countries. Government hospitals versus private hospitals. Government hospitals in the US will mean those that take Medicare/Medicaid

 

[J ROD]

You get the RVUs generated by the nps?

Yeah through a shared note. I generally see new ones alone and they do follow ups and I check on the patients after them. They have plans for me and we discuss meds and what to do. Who is ready to d/c. They order labs, meds. Run day to day of each unit. Not having to do all the notes allows me to see about twice the volume and extend my reach. In general, they do a decent job with the average case. I tend to take over on more complex cases in terms of the med management. If we are really busy, I generally also take a few patients myself and do the notes on follow up. In general it works but NP often complain about not enough autonomy. Funny enough though on complex cases or harder ones, cannot wait to ask me what to do lol.

 

[dl2dp2]

You can ask, but what actually dictates the value add is the market.

As of right now, there are a lot of instances where the supply and demand indicate that facilities should raise compensation, but very often (>50%) when I inquire, facilities are unwilling to raise compensation for various regulatory reasons, which essentially translate to the existing salary must fit into a salary framework dictated by old salary figures that didn't change or "industry surveys" that aren't well updated. This then of course causes a worse shortage. Academic facilities are especially bad. The prevailing practice is offering low 200s to a new grad/fellowship grad (with potential leadership roles), where the market value is > 300k. It's not *possible* to pay you 350k when the CHAIR of the DEPARTMENT (as a state employee, etc) only gets paid 350k on the state salary line. He may have lots of consulting gigs and so forth that bump his final income way up, but this fact doesn't help the job seeker at all. Even if the chair WANTED to bump people's salary he's constrained.

Here's the biggest problem of a centrally managed economy: underlying invariably is that facilities can't afford to bring their salary up because their revenue isn't increasing much, as salary-lined jobs are pegged to Medicaid, etc. If you raise all staff psychiatrist salaries to market you'd blow the budget. LOL. This is the foundational reality in this industry, which EVERY SINGLE RESIDENT should understand because this has huge huge implications on everything they do. There are hard caps on staff psychiatrists at a facility that takes insurance. The whole NP supervision, etc. etc. is all window dressing. You can't replace MDs with NPs ad infinitum or else they would've done that already.

 

[deleted1100659]

Some key things here:

1. Whats your location? Is the job you work at/location highly desireable? If not, that gives you leverage.
2. To add to number 1, are psychaitrists linining up to apply for your hospital? If not, more leverage
3. Can NPs practice indepdently in your state? If not, more leverage
4. Are you locked in on a contract? If not, more leverage

These healthcare administrators are spreading this myth that supervising NPs should be a free service, which is utter BS. Its not easy in many areas of the country to find a qualified psychiatrist; use that to your advantage. I will more than likely be leaving my current job over the NP issue of them trying to stack as many as possible with me for free.

Frankly how much should you paid per np? 20-25k each np, especially each state that requires physician supervision. Why? Because they CANT PRACTICE WITHOUT YOU. Its time healthcare admins understood that.

 

[Sushirolls]

You can ask, but what actually dictates the value add is the market.

As of right now, there are a lot of instances where the supply and demand indicate that facilities should raise compensation, but very often (>50%) when I inquire, facilities are unwilling to raise compensation for various regulatory reasons, which essentially translate to the existing salary must fit into a salary framework dictated by old salary figures that didn't change or "industry surveys" that aren't well updated. This then of course causes a worse shortage. Academic facilities are especially bad. The prevailing practice is offering low 200s to a new grad/fellowship grad (with potential leadership roles), where the market value is > 300k. It's not *possible* to pay you 350k when the CHAIR of the DEPARTMENT (as a state employee, etc) only gets paid 350k on the state salary line. He may have lots of consulting gigs and so forth that bump his final income way up, but this fact doesn't help the job seeker at all. Even if the chair WANTED to bump people's salary he's constrained.

Here's the biggest problem of a centrally managed economy: underlying invariably is that facilities can't afford to bring their salary up because their revenue isn't increasing much, as salary-lined jobs are pegged to Medicaid, etc. If you raise all staff psychiatrist salaries to market you'd blow the budget. LOL. This is the foundational reality in this industry, which EVERY SINGLE RESIDENT should understand because this has huge huge implications on everything they do. There are hard caps on staff psychiatrists at a facility that takes insurance. The whole NP supervision, etc. etc. is all window dressing. You can't replace MDs with NPs ad infinitum or else they would've done that already.

MGMA surveys are used to suppress physician salaries. They are used as you allude to, for dictating what is the horribly termed "Fair Market Value." Some one please step in and help me on who adds the teeth to this Scat on FMV, I can't recall exactly, little rusty on this detail. I think it is being a non-profit that dictates incomes can't be in excess of certain FMV indices. Thus, low inertia to propel salaries.

I used to believe the lie that hospitals are scrapping by and can't afford anything they are broke, have no choice but to hire ARNPs to simply survive and carry out their mission. Scat. Pure scat and lies. The things I've seen over the years in connection to different health systems, they are doing just fine. Money is wasted on Admin staff, and admin salaries. Money is wasted on lawyers for admin screw ups. Money is wasted on promoting the wrong people to middle management who propagate distressing work environments that fuel further lawsuits. Money is wasted on Admin projects buying an acquiring buildings, practices, whole urgent care networks, etc, etc, that aren't in line with their true mission, but believed to make them more profitable. The culmination of all these endeavors that are in opposition to what a non-profit driven mission should be has shaped my view that these organizations, should all be stripped of their non-profit status. Worse, on top of this, are the estate gifts that fuel these profit systems with another surge. Meanwhile small entities don't get the non-profit tax benefits that these for-profit-in-behavior entities get, compounded by their higher rates from insurance - makes competition so much difficult. Small entities are practically forced into cash only.

In summary, there are ways for non-profits to re-align, and peg their payment structure higher for physicians, which would be more favorable to recruitment and have an emphasis on physician over mid levels. But they don't want to. The lie isn't that they can't, the lie is to you and us, that they just don't want to and want to place dollars in other buckets.

If we want change, we have to take back health care in the US. Physicians have to be the admins. Not because we are burned out and fleeing clinical medicine and are willing to drink the koolaid of the bureaucracy, but because we still have fight in us and want to shape an entity. [man, all this almost sounds like a political ad to 'bring out the vote'] To change the hiring practices, and pay structure, and mid management roles. Other aspects as the formation of physicians specific groups, working from the ground up.

 

[deleted1100659]

I used to believe the lie that hospitals are scrapping by and can't afford anything they are broke, have no choice but to hire ARNPs to simply survive and carry out their mission. Scat. Pure scat and lies.

They will peddle that nonsense so much you will start to feel empathy for them before you realize its a load of crap. They hire ARNPs not because they have to but because it makes them more money and then they push the movement that it improves access to care and evil physicians are trying to suppress competition. Such a huge scam.

Simple numbers show they're killing it. My facility gets an insane number of government grants in addition to being a major facility in the state, and that money is going somewhere, just not to me.

But they also give me and even the nps this speech of "were losing money on you guys, we need to increase revenue".

The healthcare system is no different than how any other corporation works. Its all really the same thing.

 

[nexus73]

Sorry to derail my own thread, but I agree with all the above. The most egregious thing to me is the facility fee vs the professional fee for a psychiatric stay. The pro fee might be $60-200 per day, while the facility fee is $1000-2000 per day. So an MD or NP seeing 10 inpatients is allowing the hospital to bill $10,000-20,000 per day facility fee. Plus the pro fee. Obviously hospitals have overhead, but I truly doubt it costs $2000 to have someone for a day on a psychiatric unit.

 

[Merovinge]

Sorry to derail my own thread, but I agree with all the above. The most egregious thing to me is the facility fee vs the professional fee for a psychiatric stay. The pro fee might be $60-200 per day, while the facility fee is $1000-2000 per day. So an MD or NP seeing 10 inpatients is allowing the hospital to bill $10,000-20,000 per day facility fee. Plus the pro fee. Obviously hospitals have overhead, but I truly doubt it costs $2000 to have someone for a day on a psychiatric unit.

Oh boy, you are going to really be amazing when you see inpatient fees significantly north of what you are quoting. Plenty of places where the cost if more like $3-4k/day.