“This is a physician led company and we haven’t quite figured out the best way to utilize APPs.”

Does this sound familiar?

I am pleased to share with you an interview that I did with a fellow Nurse Practitioner – let’s call her “Florence Nightingale” - about a subject that she encountered in her clinic.

I’ll call it the double standard, and I wish it was rare, but it’s not.

“Florence” has been working as an NP for about a year and a half, in her current position for about six months. She works in primary care, and sees about 18 patients a day. Her office is part of a larger healthcare system, and while there is another NP in her practice, the rest of the providers are physicians. (Some answers edited for length or clarity.)

Jessica Reeves: How many patients do your colleagues see in a typical day?

“Florence Nightingale”: Several of the physicians are nearing the end of their career, or have written into their contract to keep their panel size small. One physician sees 10-12/day, another sees 12-15/day, and one outlier sees 25-40/day.

Jessica: Do you have a contract?

“Florence”: I do not have a contract.

Jessica: Do you cover for your colleagues (after hours on call, in office coverage when they are out, etc)?

“Florence”: Yes. My understanding when accepting the job was that as an NP, part of our responsibility was to cover when other providers were out. What came as a surprise is that none of the physicians cover each other AT ALL. It lies solely on the two NPs, even if all the physicians are out on the same week – which has happened multiple times! In that case, we are responsible for covering all medication refills, urgent/sick triage calls and visits, etc. [Edit to add: this is in addition to seeing MORE patients than her physician colleagues on a typical day! -Jessica]

Jessica: You found out that the physicians were being given productivity payment, based in part on work done by NPs with patients, and you were not. How did you find this out?

“Florence”: I was lamenting to the other NP that I was left out of the yearly bonus because of my hire date. The health system made an announcement over the summer that they were eliminating the bonus program for all advance practice providers and that the bonus payment in December would be the last one. I missed the cutoff by two weeks and received nothing.

We were discussing that part of our role was to complete follow ups and that it doesn’t seem fair that we work hard to titrate BP meds, diabetic meds, etc., to meet quality metrics (which in my eyes is just doing what is best and right for the patient) for the physicians to be paid out quality bonuses and we get nothing.

A physician who is newer to the practice overheard us and came into the conversation inquiring about our compensation. I am quite upfront and open (these days I think you have to be), and told him that we are paid a salary, receive no bonuses, RVUs, cost sharing, at all. He was flabbergasted and said “that is really surprising because there is verbiage in my contract about receiving a portion of APP (advanced practice provider) RVUs.” He showed me his contract, and sure enough, there is a financial incentive to work alongside NPs/PAs who generate revenue the physicians share in. This is in addition to earning quality bonuses that they physician may or may not have worked to achieve.

Jessica: Was a reason given for why physicians are being given this money and you are not?

“Florence”: I discussed with a nonclinical operations executive who told me “This is a physician led company and we haven’t quite figured out the best way to utilize APPs.”

Jessica: Any plans to bring this discrepancy up to the leadership at your practice?

“Florence”: I already have. They claim to be working on APP compensation and state that they realize there are issues with it. After telling me that “it won’t happen overnight” and that instead of yearly bonuses, they have chosen to increase hourly salaries “substantially” (to include what was previously paid out in a lump sum), I was told my hourly rate was increasing $1.00/hour.

This increase was supposed to be 4% for the annual raise based on my evaluation (which was excellent), plus whatever percentage they calculated to incorporate a bonus. $1.00/hour isn’t even 2% of my current salary.

It seems obvious that they got rid of the bonus program for APPs and did nothing to make up for this annual loss of income for APPs. Now multiple APPs are leaving the company each month, but that doesn’t even seem like enough (for them) to prioritize fair compensation and discussion among advance practice providers.

I was told that they company may choose to make the workload and responsibilities less, instead of increasing or changing the compensation structure, so that the salary is fair. In other words, work at the bottom of your licensure and don’t complain about how little money you make.

Jessica: Have you made any changes to how you do your job since finding this out?

“Florence”: This is a new development, so no. I still care deeply for patients and will still do what is right for them. But my job satisfaction has definitely tanked and I am looking for other opportunities. Mine is the only health system in the area that does not provide productivity incentives to NPs.

On a scale of 1 – 10, where 1 is not at all and 10 is the most possible, how relatable is “Florence’s” story?

I have worked in settings where there are “teamlets” of one primary care provider (sometimes an NP) plus one non-paneled provider (always an NP or PA) who takes on the acute visits for the paneled provider, along with sharing in the administrative burden by co-managing the inbox and other sidework of healthcare.

I’m not wild about this idea, but it can work for some people if it’s a good match in terms of personality and working styles. Still, I wonder: who makes the decision to work together? Is it the paneled provider and the non-paneled provider who choose to work together or does admin play matchmaker? What happens if it is not a good match? Is there recourse?

To circle back to “Florence Nightingale’s” interview (thanks so much for sharing your story, Florence!), I have not seen examples of this where there is such a lopsided financial incentive that rewards one person at the literal expense of the other. Have you?

If you have a story that you would love to share with the group, please reach out to me (click here to email). Your anonymity will be protected…you can be Florence Nightingale 2!

In other news…

Nurses are pushing back. Not just in the United States, but abroad – songwriter and activist Billy Bragg makes an excellent point about striking nurses in the United Kingdom, who are striking due to staffing shortages as well as low wages.

“Despite the spin…on the situation, people aren’t dying because nurses are striking - nurses are striking because people are dying.”

Compensation is only a part of the reason the nurses are striking; staffing ratios and shortages are another major factor. “Minimum staffing levels are not available for our patients or our nurses any day of the week,” says Pat Cullen, Chief Executive of the Royal College of Nursing Union. (Full story HERE.)

Sound familiar?

[And if you are not already familiar, Billy Bragg wrote the very excellent and thought-provoking song “There Is Power In A Union.”]

It’s been a helluva week.

Take care,

originally published January 21, 2023