What a ‘Flexible’ Nurse Costs vs What a Nurse Makes: Inside the Staffing Middle Layer

This article is part of the Nurse Flexibility Review, Nurse.org’s original research series on the new ways nurses work. This one follows the money: what facilities pay for flexible staffing, what nurses receive, and the middle layer in between; for the full picture, start with complete guide to nursing’s new flexibility.

One of the first things travel nursing taught me is that the rate a nurse sees is not the rate the hospital is paying. I remember realizing there was an entire layer of money moving around every assignment that most nurses never really get to see. We see our hourly rate, stipends, or overall compensation package. The facility sees a bill rate. The difference between those two numbers pays for the business of getting us there.

Every nurse who has worked a staffed shift has been part of that transaction, whether they realized it or not. The hospital paid one number. They received another. The space between them is a business of its own, with a history and, in at least one state, a paper trail.

New York requires temporary healthcare staffing agencies to report their finances, which makes it the clearest window in the country into how this market works. In the most recent full year, agencies there billed about $2.6 billion for temporary healthcare staffing. Roughly a third of that stayed with the agencies rather than being paid to caregivers. For Registered Nurses at hospitals specifically, the spread ran 41 percent for the year, reaching 48 percent in one quarter and topping 50 percent in some regions. Over the same period, the number of registered agencies grew from about 430 to 530.

That does not mean the entire difference is profit. There is real infrastructure and real cost behind an agency’s share. But I do think nurses should understand that there is a much bigger financial transaction happening around their labor than the paycheck they see every week.

The same filings also quietly correct a popular image. About 71 percent of the temporary workers in New York’s reports live in New York, and they mostly work close to home: about half commute 10 miles or less, and two-thirds commute 25 miles or less. Most temporary staffing is not a traveler flying in from three states away. It is a local nurse, often from the same county, working through an intermediary.

That is important because the staffing market is no longer just about traditional travel nursing. More and more of it is local nurses choosing different ways to work, while agencies, hospitals, and platforms all compete over who gets to arrange that work and how much of the total spend reaches the nurse actually doing it.

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That retained share pays for real services. An agency recruits, screens, and credentials. It carries malpractice coverage. It runs payroll, pays the employer’s share of taxes, and often provides benefits. Most of all, it produces a qualified nurse on short notice, which is a service hospitals have shown they will pay dearly for. The retained share is revenue, not profit; the filings do not show what agencies clear after their own costs. And nurses have been beneficiaries of this layer too. Agency work is exactly what delivered the peak travel pay of recent years, and plenty of nurses used those checks to pay off loans, buy homes, or reset their finances.

None of it is free, and the price is big enough to explain almost everything happening in nurse staffing right now.

What New York’s Filings Show (CY2024)

Source: Nurse.org Nurse Flexibility Review, 2026. From New York State Department of Health filings; retained share is revenue, not profit.

Hospital benchmark surveys put the average annual cost of a travel RN near $190,000, against roughly $124,000 for an employed staff RN. The same surveys put the cost of replacing a single staff RN around $60,000, with staff RN turnover running at 17.6 percent last year. Put those numbers side by side and you can see the whole board: hospitals face real turnover, flexible coverage costs them a premium, and a wide gap sits between what they pay for a nurse and what a nurse receives.

Gaps like that invite competition. App companies are betting they can connect nurses and facilities with less overhead; at least 18 gig marketplaces operate on that bet today. Hospitals are betting they can do the arranging in-house and keep the difference, and 128 of the 150 biggest-metro systems now run some kind of flexibility program, including eleven with full internal staffing agencies. Both movements exist because of the size of the middle layer. Whether either one actually passes the savings to nurses is a fair question, and one reason to read their offers closely.

In my own travel assignments, I have not always known the facility’s bill rate, and many agencies are not going to share it. I do not necessarily think that is a problem. The bill rate is part of the business agreement between the hospital and the agency, and some agencies treat it as confidential. But it never hurts to ask if that information is available.

What matters more to me is whether I understand my side of the deal. I want to know my taxable hourly rate, stipends, guaranteed hours, reimbursements, bonuses, benefits, cancellation language, and exactly what could change once I start the assignment. If the bill rate is available, it can give you another piece of context when you are comparing or negotiating an offer. If it is not, I would not automatically see that as a red flag.

For me, rate transparency is less about knowing exactly what the agency is making and more about knowing exactly what I am agreeing to. Before I sign, I want a clear picture of what I am being paid, what is guaranteed, what is not, and what financial risk I am taking on.

What a Nurse Costs a Hospital (CY2025)

Source: Nurse.org Nurse Flexibility Review, 2026. From the NSI 2026 National Health Care Retention & RN Staffing Report (527 hospitals, 40 states).

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New York’s filings exist because New York chose to require them. A handful of states publish partial data, county averages or registry lists without financials, and most publish nothing at all. In practice, a nurse’s ability to understand her own market depends on which side of a state line she works.

The filings are also starting to have consequences. New York’s 2026-27 state budget gave the health department authority to cap the share agencies retain, called the agency rate in the law, with key provisions taking effect in late August 2026 and the implementing rules still to be written. Agencies dispute the profit framing for the reason noted above: the retained share is revenue, and the filings do not show agency costs. However the rulemaking lands, it began with a state requiring that the numbers be visible.

So you cannot make your state publish agency finances, but you can use the structure. Three practical moves:

• Know what you are paying for. When you evaluate any flexible option, ask what function you are buying, in money or in terms. An agency’s share buys credentialing, coverage, and placement; an app’s fee buys matching; a hospital’s internal program buys convenience and one benefits system. None of these is free; the question is whether the price matches what you get.
• Remember the bill rate. When someone quotes you a rate, there is usually a bill rate above it. You will rarely see it, but knowing it exists changes the conversation, especially when a facility says a rate is fixed.
• Check where the middle went. When a new model promises to cut out the middleman, it rarely disappears. It moves, and the terms move with it.

What I want nurses to take away from all of this is that you do not need access to every behind-the-scenes number to make a good decision. You do need to fully understand your own offer before you commit to it.

Know what you are being paid, what is guaranteed, what can change, what protections and benefits you have, and what happens if the assignment does not go the way you expected. If you are unsure about any part of the offer, ask questions until you understand it. Do that before giving a verbal commitment, and especially before signing a contract.

I always remind nurses that a contract is not just paperwork to get through so you can start an assignment. Once you agree to legally enforceable terms, those terms can create obligations for both sides. Read the entire contract, including the cancellation language, penalties, repayment provisions, scheduling requirements, and anything else that could affect you if your circumstances change.

If there is language you do not understand, or you are concerned about what a clause could mean for you, do not be afraid to have an attorney review it before you sign. It is much easier to ask questions and understand the potential ramifications before you commit than to try to sort them out after there is already a disagreement.

There are more ways to work as a nurse now than ever before, and I think that is a good thing. More options give nurses more control, but they also give us more to compare. The better you understand the terms in front of you, the easier it is to decide whether an offer actually works for your life, not just whether the number looks good on paper.

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🤔 Have you ever seen the bill rate a facility paid for your shift? Share your thoughts in the comments below.

About This Data

The New York figures in this article come from the New York State Department of Health’s temporary healthcare staffing agency filings, which the state publishes quarterly and annually; retained-share figures represent agency revenue, not profit. Hospital cost figures come from national benchmark reporting of hospital-submitted data. Figures reflect the most recent reports available when we checked in August 2026.

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