Nurse Practitioners Paid Twice as Much as Doctors

moneyNurse practitioners (NPs) make twice as much as family doctors per patient. It costs between $130,000-$140,000 to hire one full time NP.  That is, an employer must fund  salary + benefits + salary for replacement staff when NP is on holidays.  This is a standard calculation for all salaried positions in hospitals, industry and private practice.  An NP experiences this as an annual income of around $110,000 plus benefits.

In capitated practices, individual providers roster (enroll) patients into their practice. Clinicians care for their rostered patients and see their colleagues’ patients if urgent needs arise.

Note: capitation pays doctors an annual fee, in monthly instalments, for all the care each patient requires. Docs can work towards earning small bonuses if they meet screening targets. These are bundled into the calculations below.

A full time family doctor (FP) rosters 1,600-2,000 patients, some carry more. A full time NP rosters 300-400 patients and cares for them as their primary provider with a physician serving as back-up. An NP receives the same salary regardless of their roster size.

Nurse Practitioners Pay/Patient

$130,000 income / 400 patients = $325 per patient/year.

If 300 patients, NPs earn $433 per patient/year.

Family Doctors Pay/Patient

$200,000 (net) / 1,600 patients = $125/patient/year.

For 2000 patients, an FP will net around $240,000 = $120/patient/year.

At $125/patient, family docs would earn $50,000 annually to see the same 400 patients as an NP. This equates to $40,000 + 20% benefit package. Per patient, family doctors get paid 38% – 29% of nurse practitioners.

In addition, nurse practitioners

  • Do not have headache of paying overhead.
  • Do not spend unpaid time managing overhead/office and do not assume legal risks of owning an office.
  • Do not prescribe narcotics or controlled substances distancing them from a challenging group of patients.
  • Have doctors for backup decreasing liability.
  • Leave the most complex patients for FPs to sort out.
  • Get lunch breaks.
  • Do not take call after hours.
  • Can forget the office when they go on vacation.

Many family doctors tell me the NP deal looks attractive. These docs would love a slower pace. If the government offered to pay NP rates for a roster of, say, 500-600 patients with the same benefits, I know many physicians would jump at the opportunity ($325 x 600 patients = $195,000).

But NPs spend so much time with patients! They practice unhurried holistic care. Family doctors rush and treat people like cattle.

Many family doctors would love to practice the same unhurried holistic care completely insulated from any concerns about anything beyond the 7.5 hour work day.

Income Inequality

Some doctors work faster, roster more patients and earn four times as much as an NP. People then assume that all doctors are fat cats.  No one cares about how hard a doctor works to earn a larger income.  Voters see doctors working harder in terms of cheating patients with shorter appointments. They assume that taking longer to provide care equals more care overall.

Doctors feel incensed at the injustice that NPs get paid twice as much per patient.  Marxists feel equally incensed that any worker could earn a much higher total income in the same industry.

Insurance vs. Managed Care

Government has changed Medicare from health insurance into managed care. Central planners obsess over inputs instead of outputs, costs instead of service and quality. Time becomes a key component of any input-centered system. Longer care becomes quality care. Obsession with input combines with an ideological commitment to income equality. Perverse incentives arise when central planners arbitrarily fix incomes to meet chic social promises.

In the end, patients lose out. When one provider makes twice as much per patient for easier work, the lower paid provider adjusts his or her service accordingly. He or she does not do it consciously, but it happens nonetheless.

Nurse practitioners provide enormous value when properly trained to use all their abilities as part of an interdisciplinary team. But they are not cheap. Governments know that.  For primary care, family doctors offer an incredible bargain. Politicians just won’t admit it.

[Photo credit: torontosun.com]

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37 Replies to “Nurse Practitioners Paid Twice as Much as Doctors”

  1. Dr Whatley,
    Your comments on the demands for physicians to manage their office and business are valid. Unfortunately, some of your figures are inaccurate or skewed to the extreme in regards to nurse practitioners. In New Brunswick nurse practitioners earn far less than the mentioned $130,000, between $90,000-$95,000. In addition, NPs rostered patient load is 800. So the math looks quite different.
    Regardless, I don’t see the need for an” us against them” posturing. NPs are not physician replacements. While our scopes of practice do overlap, I see these roles as complementary. I work within an inter-disciplinary, salaried team. We are booked the same number of patient visits and same length of appointments based on the patient’s needs. We collaborate extensively and we refer patients to each other based on the patient need and providers area of expertise. The evidence is clear that team-based care is producing the best patient outcomes.
    There is a consensus within the healthcare community that care should be patient-centered. I find working in a team supports this aim while also improving the work environment for the providers.

    Janet Weber
    President Nurse Practitioners of New Brunswick

    P.S We have the authority to prescribe controlled substances including opioids.

    1. Thanks so much for taking the time to read and comment, Janet!

      I shared based on personal experience with a number of different NPs in community, academic and acute care locations in Ontario. The $130,000 figure comes from the cost an organization bears to staff one FTE NP position 52 weeks of the year. When NPs are on holiday, the organization must pay for another provider to work when they are away. I agree, the NP does not see the $130,000 figure, as I mentioned in the post.

      If we use your $95,000 figure, that works out to $118,750 assuming a 20% benefit package (many benefit packages are much higher).

      $95,000 works out to $1,827 per week. If an NP gets 4 weeks of holidays, a clinic must pay 4 x $1827 = $7,308 to hire another NP to cover the holiday. This figure is PRE-benefits. $7,308 / 0.8 = $9,135 to pay for another NP to cover the original NP’s holidays.

      $118,750 + $9,135 = $127,885. This comes very close to the $130,000 figure I quoted initially.

      This comes down, again, to comparing annual salaries with MD total billings. Provincial ministries of health do not have to pay for other providers during a physician’s holidays, but it does for a salaried NP.

      I’m glad you do not see the need for an “us” vs “them” posture! I totally agree!! The whole point of the post was to share that many family doctors would be very interested in having a similar level of compensation per patient. Add that to less responsibility, and I think we would see a very large number of family doctors signing up for the salaried work with benefits at a less hurried pace.

      I have loved working with every single NP I’ve had the chance to work with. Seriously. I love having NPs on the team.

      Again, the post makes the point that family doctors offer the government an incredible deal for the services they provide.

      Thanks again for sharing your thoughts from New Brunswick!

      Kind regards,

      Shawn

      1. I have worked in family doctors offices and have never had a “roster”. I saw patients that were rostered with the practice, not with me, as well as walk ins. Most of my colleagues have worked under similar circumstances. I saw between 15 and 60 patients a day, with the average being 25. So, based on your math, with vacation time that is 5500 patients per year, which works out to 25$ per patient. However, I do want to point out that I had 2 weeks vacation, malpractice insurance, and $1000/year for cme’s, and nothing else, including health insurance. So I assure you that my salary, was no where near $140,000.

        1. Thanks Susan!

          Again, I referred to the replacement costs to an organization being $140 k. In other words, if I want to employ an NP, pay for their vacation, and fund their benefit package, I need around $140k. You, as that employee, never see all that cash, because it goes into paying for someone to cover your holidays and to pay for your benefit package. If you read through the comments, you will see this explained above, too.

          Thanks so much for taking time to share your experience!

          Kind regards,

          Shawn

    2. Very good response! I’m tired of the us versus them mentality! Primary Doctors shove (us) patients around from specialist to specialist, and they themselves are not listening to the initial list of symptoms to send us to the PROPER specialist to begin with. As someone who is already a zebra, I know more about my disease (fibromuscular dysplasia) and the comorbid conditions which often come associated, than my former PCP. Instead of only treating one symptom at a time, listen to the litany of symptoms, and put their education to the test. Rare patients would benefit with a quicker diagnosis and not suffer through the pain and isolation. I have opted to go to a Nurse Practitioner, because I’ve found their listening skills are more finely tuned and they are much more patient with the patient. If not for a NP, my 5 cerebral aneurysms would not have been identified. 3 doctors ignored my symptoms, one hospital send me home with “migraine” and stroke level BP knowing I have FMD, I’d had the HA for two months and they would not do proper diagnostic scans, and a neurologist prescribed me endomethycin. I required 2 craniectomies (left PICA and right MCA) to repair 3 of the aneurysms and a renal angioplasty for a 90% occluded renal artery. It’s now suggested that I either have EDS IV or Sjögren’s syndrome/Lupus, but FMD specialists don’t want those diagnosis to contaminate their registrant, longitudinal studies.

      A Nurse Practitioner saved my life by ordering the proper diagnostic brain scans which found my aneurysms. So yeah, work in tandem.

      1. Wow. Holly, thanks so much for taking time to share your medical history! Very challenging indeed.

        I am so happy to hear that you’ve found a great place to get care now. I sure appreciate you taking time to read and share.

        Best regards,

        Shawn

        1. Dear Dr. Shawn,
          It’s so unfortunate that physicians like you dare to write such inflammatory post/comments!. I currently, work as a Certified Family Nurse Practitioner in a California State Correctional facility. The doctors in my facility make three times the salary of NP’s , yet their work has been deemed sub-par at best and often borders malpractice in some instances! Furthermore they (MD’s) see far fewer complex patients, and when they are asked to see new complex cases they turf them to a mid-level provider. The NPs documentation compared to fellow MD’s is often more detailed and provides in depth details about patients plan of care, and educational goals towards the POC. NP’s deserve raises and should be compensated far greater then they are; in a majority of the states. We (NP’s) are held to the same standards of the law and must practice medicine using the same evidence based methods physician’s utilize. In continuum, if NP’s your area are making 2x’s the salary of MD’s then I say hooray, for them, but I can assure you this is an exception in the history of NP compensation.
          Sincerely,
          Kim H.

          1. Thanks so much for sharing your experience, Kim!

            It sounds really frustrating, for sure. I wrote from my personal experience with hiring, and working with, NPs in Southern Ontario. I imagine experiences would be different in other areas.

            I did not write to be inflammatory. I wrote to report the facts and stimulate discussion.

            I support generous remuneration for NPs. I think NPs are wonderful and provide valuable service in the right situations.

            Thanks for taking time to read and respond.

            Best regards,

            Shawn

    3. Being a team member may be realistic in your area, but at Montana State Hospital and other places, N.P.s have their own patients, do intakes and, “do everything a psychiatrist does”. Their training in psychopharmacology is insufficient and their diagnostic skills are limited. A team approach would be a great solution to this problem. A N.P. would not be given surgery patients without the supervision and mentoring of a physician. Mental illness is equally complex.

  2. I am a NP in an Ontario FHT, and your numbers do not at all reflect my practice. My salary plus benefits (just benefits, I have no pension) come in thousands below your $110,000 yearly estimate. I do not roster any patients – instead I see any of the patients rostered to my 10 physician colleagues. In a given day, I often see 25-30 patients. By my calculations, if I see 25 patients a day, I am making approx $13.72 per patient (before taxes). I am quite certain that is likely less than what my physician colleagues are paid for each 15 minute patient visit.

    Some other points:
    – I am not paid for my lunch break, which if I do get it, I most often work through it.
    – I am not replaced when I am on holidays.
    – Doctors do not provide a legal safety net. NPs are autonomous practitioners, we have our own licences, with our own legal coverage. If I screw up, it’s on me.
    – As a NP, I am making the same amount of money as I did as a RN working in a hospital, except now I do not have the benefits package – no pension, no maternity leave top up. All this despite the fact that I now have 2 extra years of graduate level education, more responsibility and more skill. In what other profession does more education and skill equal less money?

    Please do not paint all NPs with the same brush – our practices vary widely, as do physician practices. On that note – we are NOT physicians, so please stop comparing our practice to theirs. Do you compare plumbers and electricians because they both work on houses?

    I know you mentioned on Twitter than NPs seem defensive when the discussion of money comes up – I guess that is because we are tired of being second class practitioners of health care, tired of being disrespected by the provincial government, tired of working so hard for little recognition.

    Please feel free to contact the Nurse Practitioner Association of Ontario (NPAO) to clarify your misconceptions. (www.NPAO.org or @NPAO2)

    1. Thanks so much, Briana, for taking the time to read and comment! Your input improves the discussion.

      First, I’m sorry to hear that your income decreased moving from RN to NP (“same amount…except…do not have the benefits”). It sounds like you must be in an unusually low-paying contract since most RNs find the improved incomes and benefits a major attraction to move into an NP role. I hope you find one of the better positions soon!

      Second, the point of the post was to demonstrate that family physicians provide an outstanding bargain for the services they provide. I appreciate and enjoy all the NPs I’ve worked with, every single one. I love to have NPs on the team! The post was not meant to disparage NPs or decrease their value. Please accept my apologies if that’s how it came across for you.

      I was glad to hear you make only ‘thousands’ less than $110,000 and not $20,000 or $30,000 less. As I mentioned in the response to the previous comment, and in the post itself, it costs hiring organizations $130-$140,000 to have NP services available all year. Just like any other salaried position – for example, a medical receptionist – we must hire more than one person to cover the position for the entire year. We need someone to work when you are on holidays. This added cost is not seen as income to you as an individual NP. But it still factors into the cost of NP services for the year. Based on the calculations I offered in the last reply, it costs close to $10,000 (including 20% benefits) to pay for another NP to work if you took 4 weeks vacation.

      You mention that you do not roster patients. Excellent! Then clearly, your practice does not apply to the comparison offered. I did not say that all NPs work as described, only those that carry a roster that I know of. Similarly, not all family doctors roster patients either. Some pack in 60-70 patients per day. I compared family practice rosters to the NP rosters. If you do not have a roster, we obviously can’t compare your work to what I described.

      Thanks again for sharing your personal experience. Clearly a wide range of practices exists. I was not attempting to describe all NP practice patterns in the whole province (or other provinces). The post attempted to demonstrate that family doctors offer a great bargain. Many family doctors would love to work at the rates/contracts available to NPs.

      Finally, you confused me with someone else who said that NPs were defensive on Twitter (I can tell you privately who did). Check the thread. I’m sorry you feel like a second class provider. All the NPs I’ve met seem to feel quite important/respected and valued over the bulk of other providers in acute care especially. As I said, I love having NPs around and have loved every one I worked with!! I cannot imagine the province giving you even more recognition; I doubt you will find a more supportive party than the Liberals over the last 10 years.

      Thanks again for sharing your thoughts and giving me the chance to clarify!

      Best,

      Shawn

  3. Hi Shawn:
    I am sorry but you are still incorrect in many of your assumptions about Nurse Practitioners (NP), in fact quite the opposite:
    1. The Ministry of Health and Long Term Care (MOHLTC) funds Primary Health Care (PHC) NP positions which are usually at Family health teams (FHT), Community health centers (CHC) and Nurse Practitioner Led Clinics (NPLC) in Ontario the top rate of pay is 89,000 per year for a PHC-NP, one of the lowest in the country. Many PHC- NPs have very poor benefits and/or no pension, in fact one in five PHC-NP positions in Ontario are vacant due to poor wages and benefits. PHC-NPs in Ontario have had their wages frozen for over eight years. A registered nurse who has worked in the hospital for eight years earns the same amount as a PHC-NP.
    2. I do not know of any NPs who’s vacation is covered by an extra NP, as with most FHT, CHC and NPLC all the primary care providers cover for each other while someone (NP or MD) is on vacation
    3. NPs work autonomously and independently and don’t need “a back up physician”, as mentioned previously both professions bring something unique and important to the health care table, the more we work together in collaborative relationships the better outcomes for our clients
    4. NPs currently in the NPLC model register up to 800 clients, but as NPs do not roister clients in Ontario much of our work is unmeasured, but I can ensure you I am equally booked,(same amount of clients, complexity, same booking schedule as my MD partners), work the same amount of hours as my MD partners, including many hours after my work day is complete
    5. NPs do take call
    6. Perhaps we should compare apples to apples: you are trying to compare a fee for service model for MDs with a salary model for NPs. MDs work in both these models, I believe the average fee for service model MD salary in Ontario was around $360,000, you are right office overhead, staffing significantly reduces this salary and forces the MD into a rat race of “pushing clients” through. At the CHC where I work the MD salary is $160,000 with no over head costs, no staffing costs, with benefits and a pension plan.
    6. Many MDs are moving to models of care where the incentive is not to see numbers (fee for service) but a salary team based model where “the client see’s the right provider at the right time”, most NPs do work in this environment along with many physicians, and rightly so.
    thanks Wendy McKay PHC-NP MN CDE

    1. Thanks for sharing your thoughts, Wendy! I hope others reading through this will go through the comments.

      1. $89,000 income per year includes benefits. Therefore, it costs an employer $111,250 to pay 1 NP for the year (20% benefit package). But in order to compare with what a family doctor gets paid, we need to calculate the cost of NP services for the whole year. This is how all employers calculate the cost of a worker in any position. You must calculate wages + benefits + the cost of paying a different worker to cover the holiday. In order to make a fair comparison of ANNUAL costs between FPs and NPs, we must calculate the total cost of offering NP services for the year. This is a standard calculation in management but seems quite new for many readers. I appreciate you giving me the chance to clarify.

      2. You misunderstand the vacation comment. Vacations represent a cost to cover. Either employers pay the cost to hire part-time staff to cover the vacation, or the vacation goes uncovered. Either way, the work done by salaried workers must include the cost of paying to get the work done when some staff are away. If the group covers for each other, it doesn’t mean the cost does not exist. It just means the employer factored holiday coverage into the cost by hiring enough workers to cover the 52 weeks of full time coverage. For example, if every worker gets 1 month holiday and you need 12 workers at all times, you need to hire 13 workers to guarantee there’s always 12 available.

      3. NPs work autonomously but must have access to the rostering physician in the team at all times. In most teams, NPs do not have the same most-responsible-provider status as family doctors must carry.

      4. You mention that some NPs roster 800 patients. I’ve never seen this. But even so, they would still cost >$162/patient/year, much higher than family doctors at $125/patient/year.

      5. I’m glad to hear some NPs take call. Most do not that I’m aware of.

      6. You say, “Perhaps we should compare apples to apples…” and then say I compared a fee for service model. Actually, I specifically compared rostering in capitated family practices to rostering with NPs. Re-read the first paragraphs of the post.

      I’m so glad you mentioned the $360k and $160k figures since they prove my point perfectly as follows:

      The average total billings for all doctors in Ontario has been reported at $360,000. For family doctors, the average is much lower. Let’s say it is $340,000 to be as generous as possible. Overhead commonly runs 40%. Thus, family doctors pay $136,000 overhead on total billings of $340,000. That leaves a total income of $204,000 (again, very generous since we assumed family docs only made $20k less than average). After 20% benefits, that would equal a salary of $163,000 which is quite close to the figure you offered ($160,000).

      For a roster size of 2000 patients, greater responsibility, longer training, and greater medico-legal risk, family doctors still offer a tremendous bargain compared to the cost of an NP.

      7. I agree, most doctors in Ontario now work in capitated models. That’s why I wrote the whole post about capitated models (rostering).

      Thanks again for sharing your comments and offering me a chance to clear up some misconceptions.

      From the very beginning, the point of the post was to demonstrate that family doctors offer an unbelievable bargain for the services they provide. I am not disparaging NPs or the services they provide. I love working with NPs on the team! Absolutely love it!

      Cheers,

      Shawn

  4. Hello Shawn,
    It’s an interesting analogy you have presented.
    I’m not sure why you are not also as upset with the people like my supervisor who is not an NP and makes 10% more than me just because she supervises me or the RN who makes more than me because she picks up extra shifts in overtime. You see Shawn I don’t make that much more than an RN.
    I started my career as a nurse over 40 years ago. I learned early in my studies that if you “treat the psychological you’ll be better able to treat the physical” That care and comfort heals. I hope we haven’t lost that along the way over the years. I’m a little afraid we have.
    I started to work in northern outposts as an NP because doctors would not go there. I later worked a number of years in a doctors office. (The doctors were also salaried and could get vacation time and benefits, and they made more money than me to begin with). (Doctors can choose to be salaried but for some reason they mostly choose to be fee for service…wonder why that is given the concerns you have.)
    Pt.’s in my office would often say to me “I wish my doctor would talk to me the way you do, explain my test results, explain my condition so I can understand what’s going on and support and encourage me the way you do” As NP’s we take the time to educate, explain, support and encourage our patients to quit smoking, loose the weight, understand their diabetes, decrease their cholesterol with lifestyle changes, order and explain the medications they are taking, etc…. This takes more than 15 minutes to do. This is what prevents illness down the road and you need to take the time to do it. It pays off for the health system down the road, big time.
    I have worked a number of years now in a LTC facility. We have seen a 75% reduction in resident visits to hospital since I started here as an NP. 85% of the residents are on 8 medications or less because of our medication review process with the NP. These benefits have not been factored into your equation, Shane and these are big savings to the tax payer and the residents themselves.
    What is an NP worth? What is the value of an NP?…….Priceless.
    Kind regards,
    Deanna

    1. Thanks so much for sharing your comments, Deanna!

      I’ll say it again; I love NPs! Love having them on the team.

      This is the point of the post. Family doctors provide an incredible bargain for the services they provide. Many docs, not all, would love to have a similar compensation per patient as NPs so that they could work at a slower pace to provide the holistic care you describe. We all agree that patients appreciate the extra time and effort to explain, support and truly understand patients’ needs.

      I am not arguing to pay NPs less.

      In a perfect world, we could pay NPs and FPs to give patients 1,2 or 3 hours of attention if they needed/wanted it. The system cannot afford this. I’m glad you seem open to evaluating the cost of NPs based on outcomes. Data exists from the Sudbury NP clinics. They were not cheap.

      Thanks again for taking time to read and comment. I appreciate everything NPs do. I hope you can support everything FPs do, too.

      Regards,

      Shawn

  5. Hi Shawn,
    Thanks for your dedication and kindness in responding to each post. It is an important issue.
    I just hope the bargain that you are referring to is actually more efficient and what is needed. Can we ensure that in 15 min the provider is getting an adequate history, a good enough physical exam with the proper testing, to ensure a correct diagnosis with the proper treatment and follow up ?
    I know there are NP clinics in Winnipeg, for example, that follow this model and there are certain situations where you do only need that amount of time.
    We have seen though, in the elderly for example, where they have been put on 2 medications for the same thing, and because they were on one of the medications for such a long period of time, they developed Parkinson like symptoms. So now you have someone who has had their quality of life changed, is suffering and needs more assistance. They are now costing the system more money. It takes time to research these things.
    I think there is room for both to compliment each other.
    We need to ensure time is used efficiently, ensure patients are accurately assessed and ensure the proper care is given.
    All the best,
    Deanna

    1. Thanks again, Deanna, for commenting and engaging with great thoughts offered so politely.

      I completely agree with your comment about time, rushing and patient complexity! Many patients take 15 minutes just to change out of their winter clothes and make it to the exam room. Dozens of patients need 10-15 minutes just to get to the real reason they came to the clinic. That’s before you start an exam!

      You make an even more important point about outcomes. Again, I totally agree that we need to focus on outcomes. We should include patient expectations in our definitions of ‘ideal’ outcomes.

      Finally, you close with comments about providers complimenting each other. I couldn’t agree more! Team care works best. I know I cannot be all things to all patients. The more help we can get on a team, the better quality care we can offer to patients.

      Thanks again for reading, engaging and working to make things as clear as possible. Your responses display the very best in professionalism that I’ve found in all NPs I’ve worked with so far.

      Highest regards,

      Shawn

  6. Hello Shawn,

    Thank you for opportunity to engage in this important discussion. Fortunately, in a truly collaborative interdisciplinary model, not only do patients benefit, but so do all members of the team, as we each get to share our skills and expertise with others. The value of a family physician is not based on what other members of the team are paid. But if you wish to have this discussion, then please allow me to present the facts:

    Fact: Physician billings increased 61% between 2003 and 2013 (MOHLTC). While there have also been increases in overhead costs for family physicians during this time, these are unlikely to account for the increase alone.

    Fact: NPs in FHTs, NPLCs and CHCs have had their salary frozen at the 2006 rate of $89,203 (MOHLTC). You suggested to one of my colleagues above that she would hopefully soon find another position which offered improved compensation. Sadly, this salary is consistent for NPs in all of the primary care models.

    Fact: The average MD bills on average $40 per service (CIHI, NPD). If the MD sees 6 patients per hour that equates to $240 per hour. Family physicians self-report that their average overhead is 26% (OMA). Now deduct 20% for benefits and pension (which is exactly the rate that NPs in community based primary care models are allocated) and the MD would still net $141.per hour. As a self-employed corporation, some physicians are able to take home more through tax write offs.

    Fact: NPs in the community at paid $45 per hour. This is before tax. The are allocated 20% for benefits and pension.

    But lets compare oranges to oranges: the average salary of a Family Doctor is $183,355 (taken from a random sampling of 20 salaried physicians working in CHCs as posted on the 2012 Sunshine list). NPs are paid $89,203 and this has not changed in 8 years!!!

    And finally – can we please stop distracting from the real issue with talk of who is worth more, and get back to working towards full integration of all health disciplines based on evidence which improves outcomes for patients? When we finally get to that point, then we will truly have the best value for our tax dollars.

    Kind regards,
    Claudia Mariano

    1. Thanks so much for sharing your passionate comments, Claudia! I appreciate you taking time to write such a long note.

      You start by re-quoting Hoskins’ 61% raise. I encourage you to check out: Did Doctors Get a 61% Raise? It’s not true, and I wrote a whole post about it.

      You seem determined to discuss total earnings as though the post was an attack on your income. I’d love to see NPs earn more! The post describes what a great bargain family physicians offer to Ontario. If you want to learn more about physician incomes, please read: What’s My Doctor Billing to See Me? This post has had over 12,000 views, by far the most popular post on this site.

      It looks like you try to go on the attack with your “Fact” about the average physician billing per service. You have confused fee for service with capitated practice. This post compares rostered NP practices and rostered physician practices. I realize all the different models makes it hard to keep things straight, but the difference is crucial. As to your “Fact” about patients per hour, I do not know of any physician who can see much more than 2-3 elderly patients per hour, sometimes much less. Six patients per hour describes a walk-in clinic treadmill of easier patients, or old fashioned high volume fee for service where patient were brought back for every little thing. These practices represent a tiny minority of FP care in Ontario.

      Finally, you compare a salaried CHC family physician to a salaried NP: $183,400 vs. $89,200. It seems an NP earns 1/2 of a family doctor. What is your point, exactly? Are you suggesting family doctors should earn 4 or 5 times as much as an NP? Or are you suggesting family doctors should be paid the same as NPs?

      I applaud your call to focus on patients and outcomes! In the current climate of politicians accusing doctors of 61% raises while slashing services to complex patients, these discussions have to take place. I apologize if they make you feel uncomfortable.

      If you really want to dig into the data, I encourage you and your colleagues to investigate the total cost of the Sudbury NP clinics through a Freedom of Information request. You can find out the total cost, # of NPs employed and number of patients served. The data will help improve your argument, but you might not like what you find.

      Again, thanks so much for taking time to share!

      Regards,

      Shawn

  7. Hi Shawn

    This is a very informative discussion. I thought I would add my thoughts to the discussion. I work in a CHC in a rural setting. I am a PHC-NP. We are funded for 2 NPs and 2.5 MDs. Each full-time provider is to have 650 patients. Each provider gets the same benefits, pension (HOOP),vacation and education opportunities. My salary is 92K and our MD colleagues are paid 256.8K plus they get a NRRR grant of 80K (not available to NPs). All our appointments are either 30 minutes or one hour. As an NP I have the same type of patients as my MD colleagues: complex chronic conditions mostly. We work well together and we make a great team. Our patients benefit. Our physician partners like this set up as it gives them time to provide care to their patients. In this situation however, NPs are underpaid. Our director and our board agree. The NPAO is working hard to improve our salaries…and I am hopeful they will succeed.

    I find it interesting thought that it is very difficult to find physicians to work in our CHC. I think they think they can make more money working in a FHT, but as you have demonstrated it ain’t necessarily so.

    1. Thanks so much for sharing such a thoughtful comment, Nancy.

      I support higher incomes for everyone. When we reward people who work hard and provide outstanding care, patients and providers benefit. We should design creative NP contracts that allow NPs to increase their income based on performance, just like professionals in industry can earn 30% extra for outstanding work.

      I think many physicians would jump at the opportunity to earn nearly $260k!! Wow! Seriously, can you tell me where you work? I will spread the word. This seems outstanding indeed. Maybe it comes with onerous on-call requirements, 60 hour work weeks or some other terrible requirements? But if you describe a 37.5 hour work week with full pension and benefits, this is fantastic!! I will be sure to pass the word around. Seriously, please let me know where this is…maybe I can apply? 😉

      Thanks again for sharing your comments! I hope the NPAO finds success on your behalf.

      Best,

      Shawn

      1. Hi Shawn

        I work at Brock Community Health Centre located in Cannington Ontario. Right now we have one MD, 2 NPs, an RN and dietician in our primary care team. We also have 3 community workers, and a diabetes team. We are funded for a physiotherapist, social worker, and podiatrist also. We are living in a temporary facility while we await the MOH to complete to work to get our building underway. Check us out at http://www.brockchc.ca. I live in Newmarket and I commute to here because I could not find an opportunity that I liked in Newmarket.

        Right now we all work 35 hrs/week. We have a on-call phone and will soon be getting an after hours call centre. We work one evening/week and when we are full staffed will also work one Saturday/month. Feel free to contact me via e-mail if you’d like further info.

  8. Nurse practitioners are paid twice as much as doctors
    I have put comments in the text and a summary at the end. Sorry the comments did not come out in red as planned!
    WRITTEN BY DR. SHAWN WHATLEY ON FEBRUARY 17, 2015 FOR CANADIANHEALTHCARENETWORK.CA
    Dr. Shawn Whatley
    Note: This article was originally posted on Dr. Shawn Whatley’s personal blog on Feb. 14, 2015
    Nurse practitioners (NPs) make twice as much as family doctors per patient. It costs between $130,000 and $140,000 to hire one full-time NP. That is, an employer must fund salary, benefits, and salary for replacement staff when the NP is on holiday. This is a standard calculation for all salaried positions in hospitals, industry and private practice. An NP experiences this as an annual income of around $110,000, 89,000 plus benefits.
    In capitated practices, individual providers roster (enrol) patients into their practice. Clinicians care for their rostered patients and see their colleagues’ patients if urgent needs arise.

    Note: Capitation pays doctors an annual fee, in monthly installments, for all the care each patient requires. Physicians can work toward earning small bonuses (bonuses can be quite considerable) if they meet screening targets. These are bundled into the calculations below.

    A full-time family doctor (FP) rosters 1,600 to 2,000 patients; some carry more. A full-time NP rosters(NP’s do not roster) 300 to 400 (the average is 600-800)patients and cares for them as their primary provider, with a physician serving as backup (the patients are rostered to the MD. An NP receives the same salary regardless of his or her patient roster size.

    Nurse practitioner pay per patient
    $130,000 income / 400 patients = $325 per patient per year.
    89,000/600patients=148/patient. NP’s paid 50/hour+/- = 3 visits per year per patient; 3 visit per year x 600 patients is 1800 hourly visits or 3600 ½ hourly visits: this works out to 257 days of visits =51 weeks

    If 300 patients, NPs earn $433 per patient per year.

    Family doctor pay per patient
    $200,000 (net) / 1,600 patients = $125/patient/year. I have never met a family doctor that makes that little. Also most family MDs do not roster 1,600/person, more like 1300

    For 2,000 patients, an FP will net around $240,000 = $120/patient/year.

    At $125 per patient, family docs would earn $50,000 annually to see the same 400 patients as an nurse practitioner. This equates to $40,000, plus 20% benefit package. Per patient, family doctors get paid 38% to 29% of nurse practitioners.

    In addition, nurse practitioners

    Do not have the headache of paying overhead.Overhead payments are paid for NP’s via the ministry
    Do not spend unpaid time managing overhead/office, and do not assume the legal risks of owning an office. We contribute to office management and take on a larger responsibility beside direct patient care
    Do not prescribe narcotics or controlled substances, distancing them from a challenging group of patients.Not Yet; many family MD’s are trying to get their patients off opioids now; why should NP’s take this on? But we will
    Have doctors for backup, decreasing NP liability. Please see document below
    Leave the most complex patients for FPs to sort out. Most NP’s share care in a collaborative model
    Get lunch breaks. Hardly. they are given to us, but most of us don’t take them.
    Do not take call after hours. Most of our managers will not permit it
    Can forget the office when they go on vacation. Not true
    Many family doctors tell me the NP deal looks attractive. These docs would love a slower pace. If the government offered to pay NP rates for a roster of, say, 500 to 600 patients with the same benefits, I know many physicians would jump at the opportunity ($325 x 600 patients = $195,000).
    If a really great collaborative agreement was developed, Each could have the best of both worlds

    Other comments, on this timely article
    Thank-you for raising the topic, the whispering has to stop. I could share more, but will stick to this
    Many family doctors would love to practice the same unhurried holistic care, completely insulated from any concerns about anything beyond the 7.5-hour work day.
    Response
    Nurse practitioners offer a unique blend of nursing with medical knowledge. In addition to the option for proving some curing aspects, NP’s are expert symptom managers, life style coaches, preventative care clinicians and the list goes on. We would be delighted if a family physician provided holistic care which they do in CHC’s where they are accorded the time they need to do all they want based on SAMI score that also determine the numbers of patients they have in their practice, but they are in a salaried model.
    Income inequality
    Some doctors work faster, roster more patients and earn four times as much as a nurse practitioner. People then assume that all doctors are fat cats. No one cares about how hard a doctor works to earn a larger income. Voters see doctors working harder in terms of cheating patients with shorter appointments. The public assumes that taking longer to provide care equals more care overall.
    Response
    1. Nineteen physicians billed Ontario’s publicly funded health insurance plan more than $2 million each in 2012-13.
    2. According to the STAR, Overall in 2010-11, the provinces paid physicians more than $20 billion for clinical services, according to the CIHI report, which put them third in health-care spending, behind hospitals and drugs.
    3. Average gross clinical payments to family physicians and specialists in 2010-2011:. Ontario: $340,020
    4. Most FP’s are incorporated and have lots of opportunity to get tax breaks. NPs are directly salaried

    Insurance vs. managed care
    Government has changed medicare from health insurance into managed care. Central planners obsess over inputs instead of outputs, costs instead of service and quality. Time becomes a key component of any input-centered system. Longer care becomes quality care. Obsession with input combines with an ideological commitment to income equality. Perverse incentives arise when central planners arbitrarily fix incomes to meet chic social promises.

    In the end, patients lose out. When one provider makes twice as much per patient for easier work, the lower-paid provider adjusts his or her service accordingly. They don’t do it consciously but it happens nonetheless. Nurse practitioners provide enormous value when properly trained to use all their abilities as part of an interdisciplinary team. But they are not cheap. Governments know that. For primary care, family doctors offer an incredible bargain. Politicians just won’t admit it.
    RESPONSE
    1. The FHT or FHO etc receives 120,000 dollars for hiring an NP of which the NP receives 89,000. The difference lies in the benefit package and overhead which goes to the clinic. If the NP is an independent practitioner, that salary is given in lieu of benefits and over head
    2. Most NP’s give the opportunity for the FD to roster 6-800 more patients which is an increase in the MD’s rostering fee/year. The NP shares the care allowing for the MD to see more complex patients and NP to care for episodic and chronic care patients which require intense medical and symptom management which to date the MD has had no time for. The NP does not share in the rostering fee even though the NP’s sees the same cohort of patients
    3. Because the complexity of care for chronic disease patients is so intense, while they have a smaller roster, they are seeing those patients more frequently to organize care, promote self-management, reduce hospitalizations, interact with families and their concerns, make phone calls, coordinate care with the CCACs, and provide palliative care outside clinic hours which they are not compensated for.
    4. The NP’s work in patient care programs and ie in an INR clinic may see 45 patients per day. On average 14-22 pts per day are seen. Mostly all intermediate visits + geriatric assessments, 18 month well baby assessments, home visits, med reconciliations, post discharge planning etc
    5. The out of baskets fees are not shared with NP’s even though NP’s immunize, do paps, prenatals etc. The NP’s are not even aware if the MD shadow bills for this. Or… if the md can bill out of the basket, the md might prevent the NP from providing that care, in which case the NP is then not working to full scope which may compromise registration renewal and meeting the competences of the College
    6. It may be more feasible to look at what an NP offers for the pay of 50.00/hr in comparison to RN’s. who now a days make almost the same 40-45.00per hour but most with a lesser amount of education and experience. MD’s make anywhere from 75-100/hour. In my case, I make less than I did 10 years ago, have 40 years of nursing experience and am paid the same as a new grad or less than a newer grad working in the hospital setting. It cost me the equivalent of 100,000 dollars to do my NP program in university costs and lost salary. But I can tell you and my patients will tell you in that ½ hour I do everything.
    7. BY the way for those of you who don’t know it, there is a grow your own program with the ministry. If you want an NP and will hire her after graduation and allow her or him to work for you during the educational process, the ministry will pay all the costs.
    RISK : We have joint or separate liability:
    https://www.cmpa-acpm.ca/documents/10179/24937/com_joint_statement-e.pdf

    1. Thanks for sharing you long note, Diane! All the information you shared about NP practice patterns helps. There’s far too much to try to respond in detail. Thanks for adding to the discussion!

      Best

      Shawn

  9. I urge all doctors to share this news with the media, patients and voters everywhere. What the Liberals are doing is slanderous and disrespectful. I for one am hoping the OMA steps up to the plate and urges doctors to strike. They did before in 1986 (for 25 days) and they should once more. That is the only way to get everyone’s attention. And no, I am not a doctor but a very concerned patient. I do not want to see our health care eroded as doctors leave this province en mass. I am old enough to recall previous exodus to the States. Our govenrment needs to be stopped.

    1. Thank you, Anna. Many doctors remember the strike and still get chest pains. I do not think it will happen again soon.

      But I do expect that physicians will look for work elsewhere. It’s already happening again.

      Thanks so much for reading and commenting!

      Best,

      Shawn

  10. A great post, Shawn. Although not a family physician myself, I do understand the hardships that go along with running a family practice.

    Your discussion is on point. Family doctors are a huge bargain to the public. The discussion demonstrates that clearly for those that can understand.

    NPs or others who have posted here need to realize that the examples here refer to the typical situation of a family physician and NP. No need to get defensive. It is a logical discussion.

    Truth is, once a health care worker is salaried (vs self employed) the cost goes up and “bang for the buck” goes down. With a salaried worker comes benefits etc.

    1. Thanks for taking time to read and comment, Vik! Excellent comments.

      It’s very hard to convince someone when their salary depends on them not understanding. We need facts, but politicians like ‘messaging’. I’m not confident we can reverse the trend over the last few decades.

      I sure appreciation you taking time to read and comment!

      Best regards,

      Shawn

    2. Please don’t even try to compare what doctors make to NP’s. A friend of mine who is a family doctor tells me that he has never made so much money. The government is also covering many costs for running a clinic. Part of the salary of NP’s is also directed to covering overhead.

      “Doctors earned more last year than ever before. The data show the average physician was paid $328,000 for clinical services last year, from a high of $376,000 in Ontario to a low of $258,000 in Nova Scotia. (Most doctors pay their overhead – including office space and staff wages – out of their income.) Across the country, average income was 5-per-cent higher than in the previous year.DAVID ANDREATTA,The Globe and Mail
      Published Thursday, Sep. 26, 2013 10:28PM EDT,
      Nineteen physicians billed Ontario’s publicly funded health insurance plan more than $2 million each in 2012-13.

      My take home is about 4500 per month as a primary health care nurse practitioner. This 200$ more than I made when I worked as an APN in an acute care setting in 2002-2004. Since 2009, PHCNP wages have been frozen with no hope for an increase. NP’s in acute care make much more.
      When I became an NP in 2007, I had studied for 2 years, which cost me 100,000 in lost pay and study costs. This was my hope to continue in nursing, to have some autonomy in caring for patients and to participate in society in a meaningful way.
      Really, if there is no increase in wages, who cares. I’m doing what I enjoy, am thankful for a rich and fulfilling job and will continue to contribute.

      Nobody has a right to complain here in Canada. we have it way too good. What is everybody so unhappy about?

  11. Shawn,

    I agree with several of the points you make above about GPs offering a great deal at a ‘per patient’ rate. As some have said above, offering a great deal on quantity does not really mean much in terms of true value. As a tax payer, I would be happy to see my dollars working towards quality care versus quantity of care provided. I look forward to seeing the primary reform come through and hope that it will bring forward several changes that will benefit patients and all primary care staff alike (MDs, NPs, RNs, Pharmacists, etc). There are several discrepancies that exist in remuneration in community care and they should ALL be looked at.

    I find the title of your article inflammatory and although you seem to support your NP colleagues (as mentioned in your comments above) this article’s tone does not reflect that. I also noticed that there was no mention (or comparison) of PA’s role in the primary care office? I am curious to hear your take on their income and whether you would support it?

    1. Thank you, Julia. I totally agree: quantity cannot overshadow quality.

      Quality includes efficiency, timeliness, equity, access, service and more. At the same time, “great care” rationed out to a few, delivered after long waits, is low-quality by all definitions.

      I understand the title raises blood-pressure. As you know, great titles grab the reader, often have double meanings, or might even be refuted in the text.

      I did not write about PAs. I do not have current information on their training, costs, etc. It’s a great idea to pursue sometime.

      Thanks so much for taking time to share a comment. This post seems to continue to attract readers. I love working with NPs, appreciate the value they add, and believe that teams improve care overall. I’m glad NPs are paid well for the work they do.

      Best regards,

      Shawn

  12. I wish I did make 425 per patient – I have worked side by side with MD’s and had the exact same job description. Yet, I do not drive a late model expensive car can barely afford a car. I do not send my kids to Ivy League colleges. I cannot afford, like the specialist I worked with to tear my almost new home down and build a brand new one on the same site because my new spouse wants no reminder of the former spouse. I worked house calls and got paid 40$ a visit and mileage. A doctor did the same route and he got paid 185,000 a year plus expenses and an assistant. There was one exception. I was expected to see patients as far as 280 miles from my home because that was too far for the doctor to be expected to travel. So, my 10,000 car was worthless by the end of the year. So, I started my own house call business. When I moved to another state, I was not allowed to sell my very profitable business because, in my state, in order for NP’s to have prescriptive rights, we had to agree that we could not own our own businesses, so when I left-my collaborative doctor took over all my years of work and I did not get a dime. oh, by the way, he never looked at my charts or patients – just collected my money at the end of the month-patient safety is just BS -having a collaborative is just a money issue-although since we do not serve a long residency like MD’s there should be a time we have to practice under a MD before we are let out on our own-that much I agree-but we should be governing ourselves-not MD’s) I am 60 years old and starting over. At the same salary as a new grad, because that is the way it works-It does not matter your years of experience in the NP world.
    I just got written up by a house call company because I was not seeing enough patients. I have no say in how many patients I see- the MD does – I cannot see patients outside his practice and he has to call them first and make sure they are okay with seeing the “nurse”. Many refuse because they say they are already seeing a Home Health nurse. So, I have all the responsibility and none of the say so.
    Running your business is a headache – I know, but you have something left in your golden years. I have nothing. Want to change places? Gladly. By the way- I did not go to med school because I just wanted a job – to be paid fairly – I am not too uppity – but it it nothing like I expected. Mama – don’t let your babies be nurse practitioners. Be a RN – take your orders and your medicine and you will be paid more and have more time off with your families.
    PS-I do understand the math – it appears we are paid twice as much as MD’s but it never makes it to our pockets and does not impact our lives.

  13. There are 52 five-day weeks plus a day, less 10 holidays, in the MoH year, which works out to 251 weekdays of clinic. The contracts of many salaried Ontario physicians provide for MoH funding of 37 days of locum tenens coverage, at between $750-$900/day (now $725-875 after the MoH&LTC’s unilateral cut-backs) plus transportation and accommodation. That is an expense to the MoH for a year of physician coverage. The group physician is paid for 214 days at about the same rate (after the physician pays for accommodation & transportation), and that comes to nearly $226,000 for each group physician (with paid vacation). That amount is based on 1-2 doctor “groups” where overhead flows through the “community”. There may be additional funding for on-call funding, or for minor surgical, obstetric & anaesthesia services. Larger groups manage the (additional) clinic overhead funding themselves. Various physician expenses like insurance, licensing & other mandatory fees and such are paid from that. The locum cost s the MoH another $33,000 (plus travel & accommodation & travel stipend), so the FTE cost to the MoH for a salaried physician in Ontario is about $260,000 plus clinic overhead. Incidentally, for a “six hours of patient face time” day, that compares closely to what a fee-for-service MD would bill as a surgical assistant, about $150-160 per hour. (In this comparison, time spent looking at lab tests after clinic is “un-funded” – or the assistant is better paid on the basis of $ per working hour.) That may help for more of an “apples for apples” comparison, looking at the approximate daily cost to the MoH.

    1. Great comment!

      I totally agree. SALARIED docs would bankrupt the system. That’s why salaried family doctors are so rare. Government could never afford to put all docs on salaries. A small clinic, owned and operated by a physician, who bills fee for service or blended capitation/fees, is the best deal the government could ever imagine. That’s why they don’t want to get rid of it.

      Thanks for sharing this.

      Best

      Shawn

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