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Ginger: So, I’m going to get started. I want to make sure that everybody has their audio on mute. We anticipate, even if we don’t hit the hundred that registered, I suspect people will be coming on pretty rapidly over the next 5-10 minutes. Our previous webinars, we’ve actually used the audio and video. We’ve had nice-sized groups of about 30.
This is a large group to manage with any audio and video going synchronously, so I ask that you put your audio on mute, if you’re willing to do that, it will help with background noise and probably bandwidth in some ways. Also, I want to remind all of you that I will make sure we have time to answer a few questions. I suspect we may not get to all of them, but we certainly have time built into the presentation to be able to do that. I know that Cynthia Flynn is on. We need confirmation from one person, Cynthia, that you can see the full screen and hear me ok
Cynthia: Yes, everything’s fine.
Ginger: OK, great. Thank’s Cynthia. I’m not going to talk much about myself or who I am. You can learn a little more about that on our website, but I do want to share with you, I have been a midwife now for near 40 years, worked in a birth center that I helped open, have also done home birth and opened a couple hospital-based practices, and also taught in academics for about 17 years at two midwifery programs, so a long, long career really focused on maternal and child health and, in particular, on watching our midwifery profession grow over the years and what’s become increasingly clear to me, especially since I left the academic world and sort of went back out into a new phase of my career is that midwife salaries are a real problem right now, and so, many of you may be living that.
That may be the reason why you’re on here. You may be a student thinking about how you approach that first job. You may be a midwife who has been in practice 5 years or 20 years trying to reassess opportunity for reevaluating your contributions, so I hope to touch on all of that tonight in some way and give you a little insight without all the answers, but certainly, some data to begin this journey.
When we talk about valuing your worth, I decided that it’s such a frustrating and sometimes angry conversation, that we need to start with a cartoon, so here we go, “We believe in paying our employees as much as they need. Since you’ll be at your desk 90 hours a week, you won’t need much.” Certainly a feeling that midwives have, a not-so-far-off reality in terms of looking at this career track as not a 40-hour work week. At least at this point in the profession, and I’m sure this will change over time, most of our students in enter midwifery programs as nurses and working often 36-hour work weeks or less on longer days, but not necessarily the role that you take on when you become a practitioner on 24-hour call, so we’re going to talk a little bit in the beginning here about salaries and I thought the best thing to do was to give you some comparisons to see why I am so concerned and why you need to be concerned too.
We’re going to start with CNM salaries and I’m saying CNM because that is the only data that the National Bureau of Labor Statistics provides us. I can tell you that ACNM has been trying for years to get CM salary data in the data bank. That has not happened as of 2016, so I want to be very transparent in saying that. The other thing I want you to look at, just from a balcony view just before you start looking at numbers and states is the white spaces that you see on these US Maps and I want you to compare that to what you’re going to see with the nurse anesthetist and the nurse practitioners. There’s a fair amount of white space and one can assume just slightly less than, maybe, 50 percent, 40 percent maybe if I tallied the numbers up, but I chose not to.
This is the most recent data that our federal government distributes on job qualifications and descriptions. You can go into the BLS and look up “plumber”, “SEO technician”, any description you can imagine you can search the database and it is a starting point for analyzing what’s going on in the country. If you look on the left-hand side, you’re going to see employment of nurse midwives by state and they’re categorizing numbers of people, so in the white space, there’s absolutely no data for midwives working in those states. It doesn’t give you a very negotiable position to be sitting in, but there’s still hope.
If you look on the right-hand side, you’re looking at the annual mean wage of nurse midwives in the top-five paying states. Now, looking at this, you can see a high of $132K and Oregon with 108, but remember some of this data can be skewed simply by the number of midwives that are working in a state. If you go back over to Iowa, there are only 30-50 midwives in that state. One midwife may be making six digits in that high bracket and really skew the data. The moral of the story is we need more data, as you’ll see when we go through more, so I want to give you a little more insight into ACNM survey data. The last core survey data that queried ACNM members, and remember, about 52 percent of midwives practicing are ACNM members, so we’re missing, low ball it, 40% of midwives practice data and, again, the end response rate, of this particular survey, which was only 242 respondents.
Again, not really strong data for us to base much on, but back in 2010, on those respondents, they report an average salary of 114. Well, unfortunately, it’s not reliable data, because if you go back to the Bureau of Labor Statistics, and you look at midwives by state and the annual mean salary, we have a range of 67-132 and that comes out to really close to 100 thousand as a mean salary, so there’s some discrepancy there and it’s really important that you understand the data that you’re drawing information from.
So, what about our colleagues in the nurse anesthetist world? Do you see any white spaces on these slides? Interestingly there is only one on the left hand side. I didn’t even try to figure that one out, but you can also see, by employment, the vast number of nurse anesthetists in our country, so again, looking at the states with highest employment on the left, I’m going over to the right slide, the top paying states for the occupation on the right and you can see the range from 242 thousand to 192.
Again, these are all May 2016 data and I want you to just keep that 192 number in mind here as we continue. Let’s look at the nurse practitioners. Again, no white spaces, which is rather interesting. Very, very high numbers of nurse practitioners in our country, which we all know. If you look over at the right-hand side with the top paying states, the range is from 124 to 115, probably very, very realistic data, because of the number of nurse practitioners reporting or employers reporting their employees salaries.
So, what else is out there in the literature that we know? Medscape, for the last two years, has done compensation surveys for nurse practitioners. I’m giving you two different surveys on one big slide here. The survey on the left is ‘16. The two slides on the right with the purple and the turquoise are ‘17. Lots and lots of slides, but I only pulled out the ones that I thought were the most germane. First of all, over time, who and how much, so you can see that all advanced practice nurses are working overtime, but if you look at the amount of overtime on average it’s the nurse midwives who are working 40%, 11 or more hours, beyond the expected time. I don’t think that’s going to surprise anyone who’s in practice right now.
Ginger: So let’s look at the most recent 2017 survey. It looks confusing because it’s comparing ‘16 and ‘15, but it’s the last data they put out. The CRNA salary rose, the nurse practitioner (NP) salary rose, and what happened to the nurse midwives’ salary? It dropped.
The other thing that I think is important is whether compensation is included in any incentive program and you can see we’re sitting at about 15% of midwives are negotiating or being given some kind of compensation program. We’ll talk about some of those later.
So, what does that look like in terms of the future? Let me give you some good news before I give you some striking news. The BLS is projecting a 31% growth in all three of those combined APN positions, totaling to 64,000 additional jobs by 2026. Today, I just looked at the ACNM jobs center. There are 104 active jobs there. We didn’t see that 5 years ago, we certainly didn’t see that 10-15 years ago, so the news is really, really good for all of us.
The question is, “How willing are we to defend our profession and our salary to be paid in a way that, if nothing else, is equivalent to our colleagues in the other professions?” So, I decided to look at malpractice, education, and work hours with a fairly in-depth data review and do some comparisons here.
The malpractice average, in terms of national average, it’s going to be dependent on years in practice, where you’re located, the scope of your practice, but we’re generally talking Nurse Practitioner categories around $5,000 per year. The CRNA is $10-15 thousand per year and the CNM is $10,000 and higher per year with an absolute confidence that the midwife tail coverage is far higher than any other profession. And why is that? When we compare these three, because of many states that allow lawsuits to be filed until the infant turns to adult. Either age 18 or 21.
What about the educational degree? Well, if you look at the average number of months per nurse midwife, nurse practitioner, certified midwife, and nurse anesthetist they average 24 months at the graduate level.
And what about the average work week over a year? CRNAs and Nurse Practitioners, on average, work a 40-50 work week and midwives typically work over a 50 hour work week. When you think about these comparisons in salary, malpractice, education, and work hours as one of my now adult sons would say when he got frustrated putting his socks on as a little kid there’s a matter with it. That matter with it is really dependent upon us being willing to speak for ourselves.
So, let’s talk about the midwife life for a minute. It’s been interesting. I’ve been talking to some people in preparation for this presentation and what we want versus what we need is often not well balanced, because, if you read the blog, many of our new grads are desperate to just start paying off their steep student loans in addition to getting into a career path that they’ve had a passion for, for a very, very long time. Sometimes our needs to have health insurance for our family. Maybe we’re the major wage earner. They’re often difficult things to balance and I would propose to you that going about this in a very clear and precise way, maybe in a way that you might not have thought about before, could help in making decisions and choices.
Probably the worst thing you could do to yourself is think that you don’t have choices and that you don’t have negotiation power. I want to show you a helpful checklist that I found from a physician resource recruitment firm that actually gives you a way to compare practices on a variety of things of which our physician colleagues think about in a very, very serious way.
I’m not going to go through this entire document, but I can’t tell you how many people I’ve interviewed for jobs over my career that don’t even ask 4 or 5 of these questions. And it’s really sad because I think it’s evident that somehow we either want a job so bad that we don’t want to negotiate ourselves out of it or we haven’t learned a good skill set or were unable to really find the power within ourselves to speak for what we really deserve. I’m not going to spend any more time on this checklist, but I think it’s something worth your time. Whether you’re looking for a new job or whether you’re actually wanting to renegotiate the job you’re currently in.
So how do you know your worth? I’m a big believer in pro formas. For 17 years, I talked to my midwifery students about how you create a pro forma, which is a one-page document, that, to the best of your ability calculates the amount of time you want to work with income earned and needs. It’s like a business plan for being a practitioner. Your yearly revenue, so that’s all your billables minus your costs to get the profit. And I will guarantee you that of every pro forma I have helped people do, there is a surplus of $250,000 per year or more that you’re generating that you will not see in salary. Now, is that bad or wrong? No, it’s not. That’s really how business runs. Even in your own household, most of us want to have savings and ability to take care of emergencies and that’s how business runs.
Ability to take care of emergencies. And that’s how a business runs new projects, a marketing campaign whatever that might be. But the gap between what you can generate as a full-time midwife with a pretty robust skill set and what you will be paid is typically big. So, in order to increase profit, we have to increase revenue or decrease costs and that is really where you need to be very savvy about your conversations. So what is reliable data that you use?
You need to have a sense of the case mix of patients by payer type and a case mix by service provided. So working in a home birth practice, compared to a birth center, compared to a hospital-owned practice, compared to a private O.B. practice or family practice or your own practice are all going to be extremely different. So, you need to do some interviewing on the type of job you’re looking for, what a general idea of how their practice runs. Are they at full capacity or are they seeing as the average provider or the average midwife seeing 15 patients in the morning and in the afternoon or is it a birth center where you’re maybe seeing one patient per hour or one patient for 45 minutes. It’s going to have a very big difference on the amount of money you generate, in addition to the case mix of those services.
What kind of GYN services? Are there advanced skills like colposcopy, urinary dysfunction biofeedback. Are you doing lactation counseling, whatever other services might be provided needs to be calculated? There also needs to be a very clear thought of the number of births per month you will attend. What’s going on in the practice? What’s the likelihood of your time at birth, so that you can then be able to on average calculate the monetary value of those births that you’re generating, by attempting them?
I’ve already talked about additional billable procedures. Ultrasound would be another one of those on that list. First assist is another one of those. It’s really dependent upon your additional skills beyond the core competency. Then you need to know what are the charges or the average receivables by the ICD code. How do you get that information? You can do a best guess, you can do some internet research, you can ask what the charge is for your own personal office visit and see what your insurance pays the provider and make some pretty calculated decisions by that. Medicaid is kind of a gold standard in a lot of ways for receivables, but there are ways to do that without getting into price fixing laws, which can be problematic.
Ginger: What’s the percentage of overhead for each practitioner? So your contribution to the laundry being done, the lights being on, the disposable supplies. There should be some calculated percentage, by practitioner, which you have to embrace as part of your cost. Then what is your salary your entire package including health benefits, which is typically in the mid 30 percent range of the salary? That all has to be factored in as well as malpractice, continuing education, and things like that. So we’re working on a product that we’re probably going to build into our website where you can create a pro forma by plugging in numbers, but not sure when that will be ready. My hope is within four weeks, but it may be a tool that can help you begin to better conceptualize what your worth is with you doing some homework and us basically giving you the excel tool sheet to plug in the numbers.
So how do you know if you’re ready to either negotiate a job for the first time or renegotiate a current job and this is just some of my experience the some best advice from quite a bit of research done in human resources? You need to know the range of similar positions in the geographic area and the demand for jobs. That’s going to come through the Bureau of Labor Statistics data and probably the best search engine is Glassdoor.com.
It’s so fascinating, a colleague of mine recently asked for some advice a couple days ago and has been working on a six-month decision to renegotiate his salary and I think, between gaining his confidence and then doing some research and being quite frustrated knowing what other people make in that job category, and looking on Glassdoor was probably the closer for him. He went in and asked for a conversation on January 3rd and by the end of day on January 3rd an announcement was made from human resources that all salaries for the company were being reevaluated.
YOU could be the individual who brings that conversation to reality, because I can promise you, that any offer is going to start on the low end. That is how business works. And I don’t know if it’s because we’re in a caring profession, but we’ll do anything for anybody. I don’t know if you saw Saturday Night Live last weekend, but the skit on, “Oh I’ll just I’ll just take care of it. It doesn’t matter.”
It was about Mark Wahlberg being paid one point two million to redo the movie and Michelle Wallace being paid less than eight dollars an hour. Work for same talent agency and the whole skit on Saturday Night Live is worth watching. If you haven’t seen it, it is about how women, in particular, tend to just not approach this conversation but be accommodating. So discuss with your colleagues and any mentors you’ve had about experiences interviewing.
You will be surprised. People will tell you The Good The Bad and the Ugly and it’s nice to hear that and get a sense. Ask other professionals how they approach negotiations, whether that’s friends in your family or in your neighborhood that are attorneys, physicians, other nurse practitioners, not midwives.
Ask them about how they talk about negotiating and see if you can get any new ones there. And then, the most important, certainly from the Harvard Business study that I spent some time revealing. Ask yourself, “Why are you choosing not to negotiate?” Are you afraid or are you just unsure how to handle the conversation? Is it about speaking to someone with more power? How do you find your own power? So what about a new job? It’s the best time can negotiate.
Everybody’s going to tell you that. And as a matter of fact, all human resources studies I looked at say employers expect you will negotiate. Yet my experience interviewing midwives over a very long career having started many practices and running a midwifery program hiring faculty is nobody has done that. Probably I could count on one hand. You need to know that’s the norm. If you don’t ask for additional benefits, I also promise you they will not be offered. So you need to think about what could be of value to you and make a list and by making a list, you’ve got room to negotiate and and to make some decisions instead of getting nothing.
The best advice is to let the employer make the first move. So it doesn’t work really well if you decide to start your conversation with how much are you going to pay me. Typically isn’t going to happen, because we’re afraid to ask for anything at all. But it’s really good to sort of figure out if the fit is as good for you as it might be for the employer.
It’s really a two way interview or it should be. You need to listen to the offer and if it’s lower say, “Thank you. You know this is who I am. This is my work value. This is the way that I’ve worked in other jobs and as I enter this new profession this is what I intend to do.” And you need to counter with an amount you’ve decided on and quote them the research that you’ve used to come up with that salary so that you’re not just throwing a number out in the wind, but you really are coming with data-driven information. If you’re asked to disclose your past salaries they can ask but you are not required by any H.R. laws to reply to that. I would personally suggest you not. And it’s best to do these kinds of salary negotiations in person. Using technology as we are tonight becoming much more popular, certainly virtual. And then finally by phone.
So what if you’re in a current job and you want to renegotiate your salary? In my opinion about this as well as the articles that have influenced me is at any time, but you have to be honest if you believe there’s merit in the timing of the ask. You don’t have to wait for an annual review to ask for a raise. But again, you need to go with historical data. Not just what you’ve done the last three months, but perhaps what you’ve done the last six months or nine months and whether you see trending in the amount of work you’re doing increasing and the income may be your patient volume has increased.
Maybe you started with a very low patient volume in a matter of six months you doubled the number of patients you’re seeing and the income has increased as well. Perhaps you want to ask for some way of flexing your time. It’s hard to do remote work as a midwife, but it’s based on what kind of position you might be in, but there could be somewhere in that discussion about time instead of money.
Would they pay for additional professional development? Maybe that sending you and paying for a colposcopy training or first assist training or the ultrasound certificate program that includes the test and all the fees related to that, which gives you a pretty cool benefit that you may not see in your in your check but you will definitely see added bonus on that as you advance your career. What about stock partnership and bonus options? I’m not going to go into RVUs tonight.
We could spend an entire day on that or productivity cycles and how bonuses are paid out, but trust me if it’s going on in the office you need to know and you either need to be participating or know how you can participate. Maybe you want more vacation time which which they could figure out how to do, not impact your co-workers, but also not make that a salary. And the last is outside offer in hand, which is, “If you don’t give me what I want, then I’m going to go work next door.”
So the best advice for that is find an inside mentor someone who’s above you and run this by them and see if they’re your advocate. I’ve actually been in that role a few times and it’s been successful for the person seeking more money. You need to seriously ask what would happen if the company comes back and says, “OK you’re not dedicated. Goodbye. I’ll find someone who is.” So there are possible consequences.
Ginger: You need to phrase the conversation as an I/We strategy, which means the gain is not just yours but the gain is for the company and the business. How are they going to win by recognizing what you’re bringing to them? And the last key point is asking the worth if it’s annualized over 12 months. Are we are we talking about a couple thousand dollars? Is that worth it? Or are we talking about maybe five to ten thousand dollars, which could make a difference in your earning or saving potential? So here’s some reasonable interview questions and qualifying this by some carefully phrased words. It is OKAY to ask the salary range, and of course we’re talking to midwives tonight, of employed midwives whether you have the strength to that or not is another question in how you phrase that. But it is ok to ask how is a salary correlated to performance. You’ll find out if they even have a performance plan. Is there salary transparency.
This is a topic that came up on ACNM Connect well over a month ago and a fair amount of tension came out about whether you talk about salaries among your co-workers. The answer is absolutely yes, but that doesn’t necessarily mean the company fosters or will look fondly on that. How are you compensated for overtime? Big question that’s come to us in preparation. They may say it all evens out and we’ll talk about that. When were the last salary adjustments for the employees and for the midwives? Can you tell me a little bit about the financial health of your organization? People are going to know you’re really serious if you’re comfortable asking. And then will they fund training for additional billable skills? So you need to get an offer in writing which is pretty standard operation now and I cannot emphasize enough, with legal review.
It’s another area I think we’re in. Midwives are so excited to get a job. They don’t think anybody’s going to take advantage of them. The place has a great reputation, but they know very little about what may be going on when and if they ever leave. So in this contract there should be something about what your work life is like and whether you can renegotiate things in the contract that might not be there. Like start at a later date if X, Y, and Z happens. Will they pay for relocation expenses? Can you negotiate your title?
Again that depends upon the kind of midwife job. Will they give you any kind of tuition reimbursement for length of stay in the facility. Will they pay for professional memberships, certifications and CE. Again, this type of interview/questions needs to happen better in person. And then virtually (web/video conference) or on the phone. Not by email, because you really want to lead with your value. Not that you need money because you’re seventy thousand dollars in debt and you don’t know how you’re going to start paying it off.
You need to really be able to convince the person that your value is based on data of equivalent midwives in the region and your commitment to the organization and to your profession. So you need to be realistic about your goals and prioritize how you want this ask to lay out. It’s not easy, but I can promise you the more polite and prepared you are the best chance for success. And the few people who I’ve had these kinds of conversations with, if any of them are on tonight, I’ve actually said to them, “I’m so proud of you for negotiating because it is such a rare thing for midwives seeking jobs.”
So why the legal lens? Because there are some key areas you want to make sure the agreement very clearly describes. There could be a variety of restrictive covenants, not the least which is a non-compete based on a geographic region which might mean if there are two OB private practices in a medical office building and one is on the first floor and the others on the fourth floor and you leave one practice for the other you very easily could take all the patients you’ve gained with you. Physicians almost always have non-competes based on geographic region, because they don’t want that to happen and you actually are more of a commodity than you may know, based on where you are in your career.
There needs to be some objective standards for work expectations. Not that you’re going to work when I tell you to work. That’s not how it should be designed. So if that’s foggy or you’re just going to say, “I don’t care I’ll do whatever you tell me to do.” That’s exactly what will happen to you. You need to engage in a conversation about other work restrictions, like can you be a full time midwife and be an adjunct professor for Jane Doe University? Can you run your own childbirth education business? Can you be in a partnership with somebody else that has something to do with maternity care, but you don’t think it’s going to conflict with this work? What about the authority to modify the agreement? Only if they choose for that discussion or do you also have authority to have a discussion to modify? What about the notice provisions about them firing you, you leaving or any other consequences related to probation and especially the malpractice coverage and tail policy? What are the details there?
So I wanted to give you some resources on the art of the ask. I picked out my top three favorite TED Talks. Those of you watch TED talks. These are no more than 20 minutes each, that I think are really worth watching, if you’re preparing for this conversation, that walk you through a confidence building, finding your internal voice and power, and preparing yourself for the interview process. That’s highly recommended, but so is roleplaying and finding someone you feel comfortable with.
You know you can go online and look at the common interview questions giving them the role of being the interviewer and doing some role-playing. So I’m going to end with some questions that came to us online and then open up the chat board. I’ll close this down a little bit so I can read them and will we’ll go from there with your questions. How can a new graduate who agreed on a much lower than market value salary go about increasing their salary?
I think we talked about that. You need to have a little bit of dust behind you. You need to have some time to be able to collect data that is more than a month or two old. You accepted the job, you need to commit, I would say, to at least a year in that job. But if you find yourself at six months with the data making a salary that is far below what you’re generating, and you’re going to have data at that point on the types of patients you’re seeing, the case mix all those things that are harder to do in a proforma, before you’re going into that negotiation — you absolutely should do negotiate before the year is up.
How do career transitioners, such as those beginning nurse-midwifery without being an RN first, account for our experience? And do we make accommodations?
I don’t think you ever make accommodations. You come from a life experience that is contributing to where you are at this moment in your career. An example I have is one of my students out of the University of Kansas, was like the city engineer for a very large county here in Kansas City. And then she made a transition after she had her baby and went to midwifery school. Incredible amount of management organizational skills and supervising, very, very mature and went through a rapid RN program and then midwifery.
Whatever you’ve done before is who you are, that is how you describe it. And for those that are certified midwives how you make the case for the equivalency which often needs to include a fact sheet. ACNM has those. The Committee on the Advancement of Midwifery is doing a great job, but sometimes people don’t know and they have to be educated.
How do we demonstrate our worth and get paid in a practice that doesn’t seem devalue our role? You know, I think, again, I’ve answered that question. Sometimes we assume that the way it is is the way it is. And I would challenge whoever wrote this question to think about what they’re willing to do to gather the data and make a very rational conversation with the employer and talk about the growing trend for midwives out in the market as well as ACOG’s incredible value of the Midwife role on the maternity care team.
Ginger: There are numerous publications just in the last two years of ACOG really helping to educate physicians, OBs, about the role of midwives and sometimes that's important to share as well. How do you negotiate a higher salary when RVUs are consistently above the average. Again, this is a very long workshop. It's a bit complicated. I did post a resource on ACNM connect under the business group that could help with a link of how what is an RVU. How is it calculated in and how can you be remunerated for that. But probably not something we can even go into tonight, but go on ACM connect or the business group.
Do I have to wait for an annual review? We answered that one already. No you don't. What do I do with more shifts added onto the weekly schedule when someone else is out on PTO and I don't get compensated for it? This is the question about early on in the slides where you saw at midwives on average are working 11 hours more per workweek.
And, so again, it always goes back to data tracking for a period of time, not just for you but for your peers and being comfortable going together as a whole and talking about it. They're not going to fire all six midwives at the same time, unless they're going to end the practice, which remember there's always the what if question. But data will typically drive reasonable discussions if you're being reasonable in the approach. And if there was no discussion of overtime compensation in your contract you're really at a disadvantage, because you didn't talk about it when you said yes to the job. That doesn't mean it can't be talked about, but it's going to have to be driven on data now. So that's your responsibility.
What's a fair salary for per diem or a locum tenens short placement? Right now it appears that locum tenens are making anywhere between $110 to $150/hour for short-term placement which is typically not over six months. Most credentialing panels will allow a locum tenen health provider to come in and bill under the established (absent) person's name if they're on a leave of absence. So there's been a lot of discussion again on ACNM Connect about what you get for overtime.
I would say for somebody that's doing per diem work for a midwife OR working extra hours, it's sitting around the high $50s to high $70/hour. So these are not commitments like a locum tenant agency would put you in. Typically Per Diem Midwives also have established credentials if they're doing hospital births they have malpractice coverage, things that are being paid for by the locum tenant agency. So there is a difference between those two roles.
So what I want to do now is see if I can get out of this main screen and I would love to hear some questions from you. That I'll try to manage by you typing them if you want to try using your audio. That's OK. We have it fascinating. It says We have 35 participants on and 100 people registered so it's probably ok if you want to turn your mike or your video on or you can type.
Any thoughts or questions? Areas that you want to dive into? “In a region that is so OBGYN heavy, I have heard some CNMs having an offer pulled just for countering an offer.
You know, I would say Mary, the first thing to do is to know if that's fact or fiction. A counteroffer does not have to be outlandish. It can be reasonable and sometimes it's education. Especially private practices that don't have H.R. companies like hospitals hiring midwives that have access to databases about salaries which H.R. departments do work into. Private practices probably don't have that kind of insight, so I think it depends on the scenario, but it's a great question and one that would take some searching.
Are you on Lesley? Let’s go to Lisa. We don't have a birth center in South Dakota. What are the best ways to find competitive salaries when there's no historical data? Actually, you do have data from the Bureau of Labor Statistics. They give regional data and that regional data should be of some use. And you're going to find some variances but that's a starting place. The other is knowing that ACNM salary survey to today which was the Medscape data, right? And those are 7 years apart. Six years apart? And analyses that CNM salary and those would not have been students right. Typically it's sitting at about 100,000. So you can go up and down from there. And it's also relative to whether you're starting something from the ground up and whether you're willing to have discussions as the patient numbers move up which is typically how private practices happen.
I can tell you when my husband started a law practice when he was with some partners he took half the salary of what they made and then had a percentage of his revenue generated. He ended up making more than they did. So it doesn't have to be a negative. It's all about how you think about it.
Hey, Lesley. Jump in here any time as well. From Deondra, what does a typical time you need to be practicing to be a locum and do you see this trending more? I absolutely know it's growing. I have personal experience that it's growing and it's growing because we need more midwives in areas where it's working and life happens, right?
People have babies. People have surgery. People relocate with with partners moving. It's not because of salary negotiations. I don't think that's true at all. You need at minimum a year or more experience to be hired as an LT in most company’s. How do you recommend dealing with an organization that wants to pay all midwives the same? This makes me hesitant to bring up the discussion of salary bias, but that's really sad. I don't personally believe in that. And of all the jobs I've hired I've never bought into that philosophy. There needs to be recognition of maturity in whatever profession you're in.
And I would take all my buddies out for a beverage and just start the conversation. You may not come to an answer right away. But again if you're in a group practice doing this on your own is going to undermine... somebody who's going to feel frustrated or upset. So it's a conversation that has to start in my opinion as a collective.
From Sarah: We may we emailed briefly about re-negotiating a salary for current job. You mentioned finding data about CRNAs and and as an NP. Sorry you might have come on after we started that's all at the very beginning of this presentation. So we will have this posted up on our website and you'll find the data on those salaries and important information when it's posted. Thanks Sarah. The midwifery group I'm considering joining when I graduate only brings midwives on as independent contractors. Isn’t that clever? Will I still have negotiating power since I won't be getting any benefits?
Well that may be what you need to go in saying which is first of all help me understand why the model is designed like this, right? You're asking question how do all employees come into this business. Tell me a little bit about the financial stability of the business. Can you help me understand why there aren't benefits now and may there be benefits later. And if you can't pay benefits, we know that's pretty steep today, then would you be willing to pay for something else. Any new grad I urge you to stay in that job for a year. Maybe you say in a year we're going to talk about this again.
Ginger: Just be transparent because I think the more transparent you are in an interview the more likely people are to know they’re hiring an honest hardworking invested person.
Cynthia: Ginger can I just add to that? This is Cynthia. Yeah. If you are an independent contractor, in fact, you are running your own small business and you are then you know selling a service to this practice and the rule of thumb for a small business like that is you need to be bringing in gross revenues about triple what you want to pay yourself because you’ve got to pay all kinds of self-employment taxes. You have you know a marketing need and there is legal. There’s accounting. I mean you’re basically running a small business, so I would say certainly no less than double what you want to make yourself. There’s one thing you have to pay if they want to do that. So that’s my two cents. Good luck. But you need to understand you are running your own business in that case.
Ginger: Yeah, I want to highlight what Cynthia said also about legal. You need legal review to help you understand how you will be accountable for any money you’re bringing in, because no taxes will be taken out of that. It can be a big hit if you don’t know how that works. Meredith, how are you, my friend?
A wonderful midwife who I helped educate — works in an FQHC. Are our salaries typically less compared to private, by how much? How do I address this? How can I compare what I make other CNMs who work at FQHCs? So I did not investigate FQHCs. I think there’s probably access to that because you can generate salaries of people in federal and state governments. That’s open source data, may take a little bit of work, now you’ve given me something that I’m intrigued by.
Of course, they’re not worried about malpractice, because it’s under Federal Torts Claims, but I would definitely look at the BLS data for the region and if the states there and play around yourself on the website and see if you can find any FQHC salaries. I’d be glad to help you on that one. That’s a great question. What is the typical salary range for a new grad that you feel is reasonable? Deandra, that all really does play into some of the BLS stuff that you saw in terms of region.
It also depends upon where, right? The hospital, private practice, birth center, home birth. I don’t like seeing the sixty thousand dollars in our range reported… that really really concerns me and any midwife taking a job for $60,000 is just terrifying because you can see how far we are behind with our colleagues.
We actually took a dip this year in the average midwife salary. So I guess you know one marker might be and I hear this all the time maybe Lesley will talk about this. This is what I make as a labor and delivery nurse. I’m not going to go do that. If I’m not going to make more I’m not going to be a Midwife. Right? Lesley, you want to talk about that for a second?
Lesley: Sure, can you hear me?
Ginger: Not real well.
Lesley: What about now?
Ginger: Yeah. OK.
Lesley: So… you can’t. It’s like comparing apples and oranges. So when you’re a nurse you’re paid per hour and you generally work 3-12s, sometimes you have a little bit of call, but it’s not that much, whereas when you were a midwife most of them were paid salary and there’s call included. And the difference in the job itself is huge, so you can’t really compare it that way. Even though once you go back to school and you get a degree and you make more money, you have bigger loans and all the responsibility goes with it.
You should be being paid more. But we’re not going to be able to prove that if we don’t keep getting these good labor and delivery nurses to become nurse midwives and not nurse practitioners due to salary and job opportunities alone, cause Ginger and I have seen the future and the future is super bright.
So what we need is more people, especially new grads, to do things like this and pay attention and negotiate, understand their value. I did a similar thing when I was working, which is one reason I opened a birth center where I did a pro forma and showed what our value was and it showed each midwife making almost a half million dollars in profit. And that was taking a 40 percent overhead minus our salary benefits and all that. Look using Medicaid numbers. So we really need to do that because you’ll surprise yourself. You are the goose that laid the golden egg for the most practices.
Ginger: Without a doubt.
Lesley: And new grads should look into internship programs and there’s more and more of those, especially if you’re interested in Birth Center, out of hospital work. It’s a good way to get that experience and be a transition from student to independent midwife.
Ginger: So we have we have time for a couple more questions. Deondra, what’s the typical salary range? Will you post links from the webinar’s websites? This whole presentation will be will be put up on the Web site.
And again we may get a working pro forma up there for you soon.
Trying to renegotiate our hours. We find it difficult to account for how on-call hours are counted. Any tips we are typically in-house from covering L&D. I’m not sure I understand Chris if you have your audio on. If you’re on-call or are you talking about whether you’re active in catching babies or call and sleeping at home? And how to sort that out. Actual work hours. I think there is clearly three categories, right? There is how many hours you’re in the clinic and that includes non-patient time, like from the time you start the time you walk out the door. There is no call not active.
So you’re at home or on-deck or wherever that might be and there’s call and you’re working and all of that needs to be tracked and you can do that, you know, paper and pencil or you can put on an excel sheet. You need to be making sure that you’re counting the work you’re doing when you’re on call as well. So if you’re triaging, if you’re rounding, if you’re delivering, if you’re first assisting, so that you know you’re capturing revenue as well.
What’s a typical length of a contract? Most of them are at-will. That means that they can say goodbye to you Deondrea at any time. That’s just in the business world. It’s not unique to our contracts. Rarely do they say we’re going to renegotiate with you in a year. They just sort of sit there in perpetuity, which means they typically don’t change as long as you don’t say you want to renegotiate.
So it’s a bit of a trap. Unless you decide you want to put in some kind of clause that you want to renegotiate, formally renegotiate, at is at a particular point time. Here are a couple great books that Lesley wants you to know about on negotiating: Negotiating with Giants. By Peter Johnston. And Lean In by the amazing Sheryl Sandberg, again ways to begin to build your confidence and readiness to approach the conversation. It’s the best thing you can do for yourself. You’ve spent an incredible amount of time, money, and sacrifices to get to this conversation.
To go into it with answering them, “Yes I’ll take the job” before they even give you a salary, it’s just such an incredible disservice to yourself. So we hope that you take advantage of some of these resources and encouraging data that we’ve given you. We know this is just touching the surface. There could be an all-day conversation about this including building and roleplaying and really, really of all the research I did, what’s most clear to me is people and women, in particular, seem to lose the power of their voice when they approach these kinds of conversations and feel like it’s a one-way conversation… they’re not an equivalent, for lack of a better way to say it.
So, Susan, I know you want me to talk about RVUs. I think if you go on the website, the ACNM connect, you’ll you’ll find a great resource there that calculates RVUs. You’re not going to see CNM RVUs anywhere in the literature. We have a lot of midwives speaking on that topic at midwifery works but it should be really the same as OBGYNs if you’re practicing in that area of ICD codes and I’m going to take one more. Wondering how the full scope versus clinical compares in terms of new graduate salaries. So I guess what the question might be, Amelia is what if you are our full scope midwife with call or maybe you’re a midwife in a health department running prenatal STDs clinics or whatever that might be.
Ginger: Look at the NP salary. They’re not doing call. I mean my argument is, “Why do we think we should be paid less than a nurse practitioner?” I wish somebody would tell me that because I do believe that nurse anesthetists are really working in a closer way than we are compensated for. But I have no idea why it’s happening the other way and we are the ones who have to change this. If we’re not willing to change it, it’s stagnant, right?
Our salaries are not only flat we’re going the wrong way as of the most recent data the federal government has published. This is our responsibility. So I’m going to challenge all of you to dig deeper, be more confident, gather your data. If Lesley and I can help, we’re glad to do that, but we want you to succeed and be happy and have a good balance in life and not burn out. So we’re going to end it at the top of the hour. We hope you come back and join us for other webinars and it was nice to chat with all of you. Have a great evening. Bye.