Most work environments are pushing toward hospital-employed practices as starting a private practice in most/current healthcare settings is daunting/expensive. Billing, investing in an EMR, hiring and firing, malpractice, and general overhead is very challenging for established, let alone new physicians, to take on/maintain. Starting a new practice in most markets will have the physician take on poor reimbursing payors, which won’t keep the lights on.A lot of nurses are jumping out of bedside nursing and into the NP realm because the conditions working at the bedside are becoming harsher. I don't know a nursing manager or an administration that thinks twice about adding paperwork and responsibility to RN's. Everything that gets "improved" for patients comes at the expense of nurses getting more to do (and I question whether many of the improvements really are helpful for patients). There is money in nursing, but its quickly becoming tedious for the folks at the front lines. During the economic downturn, RNs could always find jobs wherever they went, overtime was plentiful, and you could work your 3 days per week and be done, which is a significant perk. But the work is direct care and very service oriented. More folks are getting into nursing with the expectation to use it as a stepping stone rather than a career. I'm one of those folks. Every one of my RN friends who is the least bit self motivated doesn't see the bedside as an appealing long term prospect. Its been good to me, but it was never my longterm plan. In addition, the benefits of being an RN are benefits that RN's earn from working hard... they aren't handed to us. So the fact that people are passing through nursing to move on to NP means that more NPs will be out there looking for work.
I'm not really sure how having NP's flood the market will work out. I suspect it could drive down wages, but it also could help fill gaps and expand the number of jobs out there for NP's. I don't have any doubt that more states will move to granting NPs full autonomy within their scopes of practice like what already exists in around 25 states and the federal government. That's not even something that I give a second thought to, its just going to happen.
Already, I hear of folks that are having a hard time finding preceptorships for their NP program clinicals due to so many NP's out there having tons of NP students they are already helping out. That kind of points to a cluttered job market, but I also think that as corporations continue to consolidate healthcare entities, they are also looking to NPs as ways to fill positions and get coverage. I don't think this comes at the expense of physicians either. I personally know that my facility has a tough time recruiting physicians, even with good location, generous benefits, and decent pay.
I think that the new crop of physicians coming out of school is a different breed than the physicians of the past, and a lot of them are looking for better quality of life. I know quite a few new doctors who don't like the idea of trying to build a miniature kingdom and be a slave to it, so they opted to become employees of large systems rather than hang out their own shingle to do business. They get paid less, but they find the tradeoffs to be worthwhile. But even things like culture change have an effect on how the labor market plays out. Just like RNs are opting to move away from bedside due to the hassles and not the money aspect, I think new docs will opt for some of the perks of being an employee vs being a practice owner. And with that comes different hours and workflow.
Exactly right about the barriers to opening up one’s own shop. Huge factor. I think the best that a new physician can hope for is to be taken on in a lucrative group practice, and even then, I’m seeing lots of folks that do that being taken on as employees rather than partners and shareholders. And maybe that’s been true for new physicians for a long time. It’s hard to imagine many scenarios where a new physician comes out of school like a dentist and says “let’s set up a doctors office so I can work!”. The dynamic these days is that over 50 percent of physicians graduate to become employees. One of the draws for phsyche from a business perspective is that I can open up shop basically out of a suitcase. Anywhere I have two chairs can be an eval room, and a switch to cash pay is always an option if reimbursement issues are causing headaches and overhead. But doing something that you can stand to do all day is helpful. If the thought of seeing psyche patients all day turns someone’s stomach, they should stick to seeing all the psychiatric patients that will still manage to find them in their urgent care, ER, family practice, specialty clinic, or hospital floor, because you better know for sure you’ll be seeing them there to deal with their health issues before you refer them to psyche. Chances are you’ll have to put up with more drama in those scenarios that the psyche provider. I love reminding folks outside of psyche of that aspect.
Do you see mid level provider wages increasing in the future? Average of 100k seems fairly low for the work they do.Exactly right about the barriers to opening up one’s own shop. Huge factor. I think the best that a new physician can hope for is to be taken on in a lucrative group practice, and even then, I’m seeing lots of folks that do that being taken on as employees rather than partners and shareholders. And maybe that’s been true for new physicians for a long time. It’s hard to imagine many scenarios where a new physician comes out of school like a dentist and says “let’s set up a doctors office so I can work!”. The dynamic these days is that over 50 percent of physicians graduate to become employees. One of the draws for phsyche from a business perspective is that I can open up shop basically out of a suitcase. Anywhere I have two chairs can be an eval room, and a switch to cash pay is always an option if reimbursement issues are causing headaches and overhead. But doing something that you can stand to do all day is helpful. If the thought of seeing psyche patients all day turns someone’s stomach, they should stick to seeing all the psychiatric patients that will still manage to find them in their urgent care, ER, family practice, specialty clinic, or hospital floor, because you better know for sure you’ll be seeing them there to deal with their health issues before you refer them to psyche. Chances are you’ll have to put up with more drama in those scenarios that the psyche provider. I love reminding folks outside of psyche of that aspect.
Wages for anyone out there in any industry is tough for me to predict. It seems like it’s hard to compel any employer to take their workforce needs to the next level and commit to higher wages unless they are in dire straits. I’ve noticed that employers will try anything they can to avoid raising pay, and often will try to go without optimal staffing to avoid getting locked in to a highly paid employee. In the hospital system for RNs, facilities pretty much need to have their backs against the wall with a literal staffing crisis before they put down an investment on paying staff more, because that act alone really locks them in for the long term. They will pay double for a temporary travel nurse because that gives them flexibility to send them away when they don’t need them anymore. But if you start a nurse at, say, $38 an hour, you are stuck with that employee, and they will always want at least a decent cost of living adjustment every year. Once an employer sees that they are walking away from money by not staffing well, they start to inch up salary. But realistically, even with labor shortages, it seems rare that these days anyone can just name thier price at any location in the general workforce, and this is even true for new physicians. There are some places that clamor for a certain specialist, and will stretch their budget a bit to recruit, but rarely is there anyone that can show up in the city of their choice and demand more than the market will support. So for my industry in my anonymous state, I can graduate as a psyche NP and certainly act too big for my britches thinking that since my state has a dire shortage of Psyche providers, that I should be able to take advantage of the situation and demand $180k right out of the gate. But there’s a point where nobody is going to take me seriously. Same thing for a google engineer, or anyone else that has to bring in value. And realistically, most of the workforce is individually expendable. If a google engineer makes someone mad at work, there is always someone out there to take their place.
So as far as PA and Np wages, I think they will go up like they have been, not because NPs or PAs are rare (schools are cranking them out at a high pace, too), but because finding a good one is important, and you have to meet a certain threshold for pay in order to get people to show up to work. As an RN I can work 3 days per week (36 hours) and pick up a little overtime and make close to $100k. No call, no terrible hours, no 5 day workweeks with unpaid overtime. I won’t take an Np job that requires more of me for $100k. There might be someone else that will, but an employer can roll the dice on whether to sink money into someone like that and risk them walking off to someone else to work. So I think wages will continue to rise, but not really due to shortage, but because there really is a price at which folks won’t take jobs, or if they do, they won’t stick around and create value.
Remember, lots of folks out there work in critical jobs for less than $100k. Police officers and military personnel carry around lethal weapons for typically less than that. Even a bus driver can make a mistake costing millions, yet make less than half what a low paid NP would make. I’ve found that I live really well by my own standards starting at around $70k. When I was making that much (I make more now), I felt like I could buy pretty much anything I wanted to have and not worry about it. I’m not talking boats or lavish expenditures, but certainly things like a $1000 bike and all the fixings, or any tool I want for a project in my garage. Without discipline, I could end up like my friend who tends to buy several tools at once, which isn’t conducive to feeling well off making $70k per year. In areas without high cost of living, $100k or above means not worrying too much about money, even though you won’t get rich.
I’ve really liked healthcare, particularly nursing. The school where I got my RN charges less than $10,000 for the whole associates degree (my hopspital I worked at actually paid for my tuition, so even that low cost wasn’t on me). My pay started out at around $26 an hour, and within 2 years I was making well over $30. My NP program is more expensive than many out there, but I could have gone to one that costs less than $30k for a program that would take a nurse with an associates and turn them into a masters degree NP. That’s a great return on investment. Other degrees out there produce folks that are in demand in fields that pay quite well, but how many of those folks have much control over where they live? I could go work anywhere in the US, and even many places around the world, and find good paying work.... anywhere. I could leave my city tomorrow, and have several job interviews next week waiting for me in a different part of the country.
This is running long, but I should mention a girl I went to school with. She was 21, and came out of school with her associates in nursing. Worked on her bachelors before we were even done with the associates. A year after graduating, she got into an Np program. Worked while in school. And graduated at 24-ish to get a job in Seattle making $180k per year working in neonatal/Peds. No debt. In our city, with way less cost of living, she still would have started at around $130k. The job can be stressful, but not much more stressful than many others.
That’s nursing. PA is a bit different story, but I know folks that have done quite well. It’s more of a gamble to pursue PA if you don’t have fantastic grades. I’ve seen several folks firsthand who would have been practicing as NPs already if they wouldn’t have spent their time chasing PA school with less than stellar grades. And these aren’t grades that would have been disqualifying for them if they had applied even 5 or six years ago. It’s competitive and expensive to do the PA route. Financially, I crunched the numbers, and even someone going to one of the more expensive RN programs one can find at a private university that uses it as a cash cow is still better off doing something like a $75,000 RN program and going to a cheap Np school. Pa school, along with cost of living for my family, relocation, and housing for 2 years would have cost me as much as a decent house, and that doesn’t even account for lost income for the duration of the program (which for me would have been $60k in lost wages for 2 years).
