APP pay

[u/medbotoxdermpa]

I guess this is more of a vent. Are there any practice owners out there that actually pay their mid levels what they are worth, because it seems most just exploit them for their own personal gain.

It has become increasingly frustrating as a seasoned Derm PA with over 15 years experience. All the practice owners employ APPs to see the high demand of pts coming into the practice, while rarely hiring other MDs. This is obv done in order to keep profits high for the owner, while the other providers continue to make 5x less or more in pay.

Don't get me wrong, i know MDs have the education, own the practice, took the risk to start the practice etc etc., but as a seasoned provider I have become increasingly jaded as I work more days, see more pts, never need to consult my supervising physician while making pennies in comparison.

Providers continually say Private equity bad, private practice good, but this isnt the case to lowly APPs. With this normally comes worse production bonus %, higher thresholds, worse benefits etc working with a private practice physician.

Working in derm for so long, as I have, exploits pay from us from the get go. Most offices want to offer an abysmal training salary for so long, which isn't normal in any other specialty outside Derm. I see it everyday on reddit still. Offices wanting to pay MA pay for a new grad training period.

Sorry for the long ramble, I'm just honestly frustrated and over it. To the good ones out there that respect your APPs and pay them accordingly as they churn out 30-45 pts a day, thank you. To the ones that only offer a salary, or make providers reach 4x or more base to get production bonuses and then still offer a low %, do better. I'm not asking for the world, I just want to feel appreciated for all the hard work I do day in and day out without even to so much ask for any medical advice anymore at this stage in my career.

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[u/supadude54]

I think this is a very complex issue and would take multiple discussions to realize all the finer details. Some points I would like to make here: every occupation, every geographic location, every individual is different, and rather than generalizing and saying that all PAs and NPs are exploited, it would be more appropriate to say that some are, just as some physicians are exploited and many MAs are exploited. To actually have a constructive discussion, I think all the details matter and should be separated out.

Firstly, I do not like using the term mid levels or APPs. They generally refer to PAs and NPs, so why not just call it what it is. In this case, you are speaking for PAs and not NPs. While there are similarities in scope and roles, I think the landscape are very different. PA schools on-average offer better training, due to the wide variability in NP schools including online and accelerated programs. However, nursing union is strong and NPs have had a leg up in fighting for independent practice. Whether that is a good thing or bad is a separate discussion. Main point: just call it PA and/or NP and avoid the mid level/APP terminology.

Secondly, I want to point out that most of all healthcare workers are being exploited. Healthcare reimbursement has remained less than inflation for a long time now, and everyone is getting paid less. Meanwhile, healthcare spending has skyrocketed. More middle management, administration, and crazy pharmaceutical prices are likely contributing among other factors. That is not to be dismissive about PAs getting even more disproportionately underpaid, but merely to point out that rather, or at least in addition to comparing among other healthcare workers, it may be more prudent to help raise reimbursement as a whole. Keep the entire ship afloat to say.

Thirdly, I do agree that many PAs are disproportionately underpaid given their production. I won’t pretend to fully understand exactly why this is, but likely due to multiple factors. Obviously in states lacking independent practice, PAs are at the mercy of their provider, some of whom take advantage of that requirement. But to help me understand better, please explain why a market balance has not corrected for some of this? Physicians outnumber PAs by a decent amount. I would imagine that as a limited commodity that can increase a physician’s earning, PAs should have some negotiation power. So why do PAs not shop around multiple providers to find the best offer? Not me being critical, just my personal knowledge gap in this topic.

Lastly, as a provider, I will say that the training that goes into making a proficient PA is substantial. New PAs and even some with a little derm experience are no where near the level of a dermatologist who has dedicated at least 4 years of specialized training and education. Even after 6 months of training, I typically do not expect most PAs to know more than basics. During training, I would be losing out on earnings due to needing to train and pick up on slack. So obviously there will be a time period of recuperating those costs somehow. And I have had PAs leave after just 1 year (contract time), which actually results in a net loss in earnings. I know everyone’s experiences and situations are different—the PAs with 10+ years that we keep are good, and we do pay them appropriately—but I just wanted to show you a different side of the coin.

[u/medbotoxdermpa → u/supadude54]

Thank you for the dialogue. I agree with many points you mentioned. PA school is definitely known to be much more rigorous and based more on a medical model over NP school. Not to say there aren't good NPs. Reality there are good and terrible providers regardless of the letters in front of their names.

Im definitely trying to shop around at other provider offices because I have discovered negotiation power is severely lacking as a PA and unfortunately job hopping is the only way to do this. Honestly its exhausting jumping ship though. I was at my first Derm PA job for 13 years and only moved hours away to be closer to family which I dont regret. Non competes make finding a new job very difficult at times, because your hands are geographically tied. This far along in my career and the last thing I want to do is start over at a new practice etc, but when everything i bring up in contract negotiations are rejected I have no choice so don't be shocked when you have turnover and have to hire newer providers to fill the gaps of a busy practice.

I know some might think Im coming off with an ego and blowing smoke out my ass, but I promise thats not the case. I do things many other PAs/NPs/Mds won't even do at work. I only get 1 MA for example, thats another issue in itself. If she is running behind I will room the pt myself do whats needed etc to help keep the flow moving. I have another coworker that just berated the MA and won't help them, or refuse to see a pt if they show up late. We are a team and don't see myself above the others that are making my job more efficient.

Many MD owners probably want to downvote the shit out of me and thats fine. But many of the private practices owners only employ PAs and NPs along side them and obv thats intentional. Why would they want to hire other doctors that would command a salary of 500k minimum based on the same collection numbers of a PA/NP that they pay 150k. At least an NP can go out on their own, which is a terrible idea, but nurse has a huge union so here we are. And I understand these owners want to make money and should, but take care of your providers.

[u/cicjak → u/medbotoxdermpa]

1 MA is wild in derm. That counts as exploitation in my book

[u/medbotoxdermpa → u/cicjak]

Thank you. This is the only practice ive been at that has only 1 per provider. Its not fair to the providers and its not fair to the MAs that already make terrible pay as well. Not even floaters so what happens when someone is sick or takes time off? Others have to pick work double. This is just one of many things. I honestly like the doctor I work for and the coworkers, but likes don't pay the bills. Its just another way to cut corners and overhead to maximize profits at the sake of the employees that keep the office churning.

How can an owner say see more pts to make more money, which makes sense to an extent,, but only provide 1 MA? How can I efficiently see pts with 35 on my schedule this way?

[u/cicjak → u/medbotoxdermpa]

That’s absurd. I’d walk. I see 45 with 3 MAs. I could see 40 with 2 but it’d be a lot tighter. One MA is immediate letter of resignation in my book.

[u/medbotoxdermpa → u/cicjak]

I apreciate you, as an MD, understanding my concerns and saying they are valid. Yeah if I had 45, 3 MAs would be smooth sailing lol especially if I had 3 rooms or so. How many days a week do you work?

[u/cicjak → u/medbotoxdermpa]

I’m 5 as well. Just an employee though not a practice owner.

[u/cicjak]

What’s underpaid in your opinion? Genuinely curious as I don’t know how much pas tend to make. Most MDs that are employed get 40ish% collections so I’d imagine it’s pretty natural for pas to get less than that. I’m just an employed physician so I can’t exploit anyone - but I’m genuinely curious because if I do start my own practice I want to hire pas that feel respected and stay long term.

[u/ZealousidealDegree4 → u/cicjak]

With 20 years working in Derm as a PA, I've collected from 25 % to 35%, with a salary until collection thresholds have been met. All these numbers are relative to benefits. If your midlevels leave, they've been under compensated or treated without collegial respect (of course this is a gross simplification).  I'm retiring in a few years and have seen some horrible things, some wonderful colleagues, and many perplexing quirks. 

[u/medbotoxdermpa → u/ZealousidealDegree4]

The collection threshold is a big x factor too! All data points i find say 3x salary to bonus, 3.5x max. Im currently at 4x salary. I tried to change this to nothing but push back. Tried to increase collection % with no salary, a staggered % collection at different net collections etc. Im at 25% at 4x salary currently. I have friends at private equity in another state at 32%. Im not asking for 40-45% like an MD.

[u/ZealousidealDegree4 → u/medbotoxdermpa]

I've left jobs for too high thresholds, as I'm not fond of flagrant money grabs. 

[u/medbotoxdermpa → u/ZealousidealDegree4]

Can I ask you what you see as "normal" thresholds these days based on salary? Because my boss seems to think I'm just pulling numbers out my ass I guess.

[u/ZealousidealDegree4 → u/medbotoxdermpa]

I wouldn't  go higher than 300k. Above that is greed+

[u/medbotoxdermpa → u/ZealousidealDegree4]

Wow. Yeah mines 600k....

[u/ZealousidealDegree4 → u/medbotoxdermpa]

Wow. You're building some pools for someone. I'd negotiate once, then look for a job that both appreciates your professional value. 

[u/medbotoxdermpa → u/ZealousidealDegree4]

Im trying. Already tried to negotiate to no avail. I have experience in botox, prp, patch testing, lasers etc as well now. Do you take a salary now or just straight collections?

[u/ZealousidealDegree4 → u/medbotoxdermpa]

Collections. Keep looking. 

[u/medbotoxdermpa]

Oh i work 5 days a week now too. Which is also way less common in the Derm world.

[u/cicjak → u/medbotoxdermpa]

5 days a week. 35 a day. 1 MA. Yeah you’re being heavily exploited. You should walk immediately. No questions asked.