IDSA response: Guest post by Dr. Dan McQuillen

The following is a guest post from Dr. Daniel McQuillen, IDSA Chair for the IDWeek 2016 Program Committee, and President of the Massachusetts Infectious Diseases Society.

With the acknowledgement that IDSA needs to expand communication/marketing efforts in this area, I wanted to offer some information on ongoing activities our society has been engaged in for several years, beginning with IDSA’s leadership level membership in the Cognitive Care Alliance, an organization that has evolved from a loose coalition to a more formal structure last January. The Alliance hopes to take advantage of the collective power and footprint of cognitive specialties to advance the agenda that the current payment system seriously undervalues cognitive services. Change is slow and incremental in this area, but some of the reforms in payment delivery coming along offer opportunities for ID to improve our reimbursement position in the clinical arena and more importantly in the non-clinical arena (antibiotic stewardship programs (ASP), infection prevention (IP), overall system quality). You'll note that the Alliance member who signed this letter to the Senate Finance Committee (John Goodson from SGIM) is also the author of the recent NEJM article regarding fixing the Medicare Fee Schedule.

IDSA representatives to the AMA CPT/RUC committees have been involved in development and valuation of codes for physician supervision of OPAT infusion, RVU revaluation (upwards) of Evaluation & Management codes and transitional/continuing care codes. In addition, the IDSA Board approved a partnership between the Valuation Workgroup that I lead and The Advisory Board, a consulting group with a healthcare focus, to formally develop the concept of an ID Hospital Efficiency Improvement Program. Such a program will contain ID service lines that are threads throughout healthcare systems, and can serve as templates for members to use when they are proposing new or expanded ASP, IP and OPAT programs to their hospitals or systems. The IDSA Board of Directors previously funded our work with an external expert valuation firm to establish that the benchmarks for “fair market value (FMV)” for ID executive compensation should be higher than the FMV numbers usually thrown out by hospital executives at ID docs. The compensation survey just published by the IDSA Clinical Affairs Committee (CAC) complements this and represents an effort to generate accurate data to counter the inaccurate data promulgated by MGMA and Medscape, not a ‘spin’ that everything is fine. It is just one piece of a broad effort to bolster the value of ID specialists to the systems they work in and support. I note that SHEA has recently surveyed its membership on compensation and await a report on the findings in hopes that it serves as another more accurate benchmark reference. The FMV data along with examples of medical executive co-management agreements for non-clinical activities with sample contracts can be found in the “Value of ID Specialists Toolkit” on the IDSA website (membership login required).

A major thrust of what the IDSA Clinical Affairs Committee, Value Task Force, and Valuation Workgroup have been doing for several years is to establish a robust set of tools with supporting evidence that will serve to increase the benchmarks for what we get paid for our non-patient care activities. New trainees coming out of fellowship have little idea how to establish the value of and negotiate for fair compensation for those activities (I know I had no clue). Success in these efforts will go a long way to increasing overall compensation and have potential to yield far more reward than increasing payments for E&M services would. Our specialty’s inherent altruistic nature, especially in academic settings but still in many clinical practice settings, gives our expertise away with too much ease. We have to change that.

Finally, two IDWeek plugs: the IDSA CAC has organized a session for several years that explores the issues of Health Care Reform as they affect our specialty. This year will feature talks on Health Care Reform trends by a speaker from The Advisory Board, ID-led ASP, and how ID specialists fit in a bundled payment environment. Second, in lieu of their annual Business Meetings, the Presidents of IDSA and HIVMA will be hosting an ID “State of the Specialty” Town Hall Meeting Friday evening at IDWeek. Please attend with suggestions in hand.

The delusion continues (part 3)

In response to my last post a reader emailed me the following: Very easy to sit at a keyboard and throw blog bombs...  I would be thrilled to hear your constructive suggestions for a solution(s).

Fair enough. I'll address that. But it's important, I think, to first say a few words about this blog, which is now in its 8th year. From the beginning, we wanted to make controversial issues a focal point, and the issue of the ID workforce (or lack thereof) is controversial and a topic of great interest to readers. In addition, we welcome comments and guest blog posts to offer alternative viewpoints. Eli, Dan, and I don't always agree with each other (as is evident in our posts). The only comments that are censored are those advertising black market erectile dysfunction drugs and other products. And all requests for guest posts have been honored unless the author has conflicts of interest with industry. So readers, please feel free to respond to our posts.

My comments on the workforce/compensation issue and IDSA's response are made in the context of my experience with these issues. In my former job as an infectious diseases division chief in an academic medical center, I had firsthand experience with the difficulties of recruiting fellows and faculty, the inequities that resulted from a purely RVU-based compensation plan, and the toll this took on teaching and morale. At the same time, I was observing a private health system across town crank through a multitude of infectious diseases doctors, each of whom left practice once their guaranteed salary expired and they one by one came to the realization that they couldn't generate enough RVUs to maintain their salaries. Several of these physicians became hospitalists. In my current position, I see my division chief struggling with trying to balance his budget, offer salaries that can compete with other hospitals and medical schools, deal with ever increasing consultation volumes and expectations for rapid responses to consult requests, while trying to minimize the stress all of this has on his fellows and faculty members. We now have starting salaries for brand new nurse practitioners that are within a few thousand dollars of junior ID faculty salaries. I'll be the first to admit that my experience may not be the same as others. In the IDSA compensation survey, one respondent reported a salary of $1.45 million, so obviously his situation is quite different than mine and his views on these issues probably are as well.

I did a little more research on salaries by looking at the AAMC data. The median salary for an infectious disease assistant professor is $152,000, while the median for a hospitalist assistant professor is $207,000. For a third year internal medicine resident, that's a huge difference. At the associate and full professor levels, hospitalists still earn more money than infectious diseases specialists. Moreover, hospitalists salaries are rising yearly at a higher percentage than ID's, so the difference continues to expand.

Another interesting finding is that of salaries for chairs of Departments of Internal Medicine. Unfortunately, if you're an infectious diseases doctor you'll earn significantly less than your chair peer who's an invasive cardiologist, a difference of about $350,000. And what do cardiologists learn in their fellowship about being a department chair that would explain that difference? I hate to sound like Donald Trump, but it's a rigged system. And it follows you throughout your career.

As for constructive suggestions for solutions, I've written about this in older posts, but here are a few:

• Focus on the parity with hospitalists, since that's our biggest threat with regards to recruitment of residents into infectious diseases. Until ID salaries are at least as good as hospitalists', there's little reason to think that we will turn this around. 
• Consider shortening the ID fellowship to positively affect the cost-benefit calculus of additional training. Do trainees who plan to enter private practice really need hands-on training in research or scholarly activities? 
• Develop hybrid models of training to lessen the economic impact on trainees (for example, integrate ID training with hospitalist practice). Various models could be envisioned—such as one month hospitalist attending, alternating with one month ID fellowship. This would increase the fellow’s salary, and even if the total duration of training were extended, may entice more residents to consider ID training. Some would probably continue this model beyond training into employment. 
• If IDSA is working hard to address these issues, it's not apparent from their website or communications with its members. Most importantly, in my view, IDSA needs to own the workforce issue and honestly deal with it. And that begins by calling it what it is--a crisis. A crisis, magnified by the many problems that are in the news every day, like Zika virus and antimicrobial resistance. I'm not a communications specialist, but it seems to me that these issues could be highlighted to help our cause. 

Unfortunately, the two articles and editorial published this week in IDSA's journals spin an unrealistic view of the problem. I doubt that the your-salary's-not-as-bad-as-you-think-it-is campaign will have much impact. Time will tell. In December, we'll see the results of the next Match. 

Are there too many ID specialists?

As ID fellowship interview season begins, there have been some interesting posts on the program directors’ list serve. After last year’s historically awful match, program directors are looking for answers, and finding none. A longtime program director opined that “there are too many ID programs”, referring back to the famous words of Dr. Robert Petersdorf that we’ll eventually end up “culturing one another”. This individual argued that ID programs should drop their research emphasis and instead train fellows in the skill sets they’ll need in community practice (infection prevention, stewardship, clinical microbiology, basic business principles, etc.). Furthermore, the argument went, the reason IDSA has been slow to respond is that the society leadership is over-represented by academic ID physicians. 

Now, it is objectively true that we have too many ID training programs when compared with the existing demand for training….but I frankly hadn’t considered the argument that we simply have too many training programs compared with actual future need for ID physician expertise. So I went back and pulled the piece in which Petersdorf made his argument that we are training too many ID docs. Interestingly, his argument about how ID programs should adapt to future needs was the exact opposite of that being proposed by the program director mentioned above. Petersdorf argued that:

“...the existence of specialists in most community hospitals will lead to fewer referrals to the teaching centers and the resulting lack of patients will lead training programs to atrophy. Infectious Disease is destined to function best as an academic specialty whose trainees should pursue careers primarily as investigators. The number of clinicians leaving training should be reduced and not further glut the marketplace; they should be based in academic divisions and devote their clinical time and effort to the care of complex referrals and to indigent patients.” 

So which is it? Do we have too many training programs (and thus are counter-productively trying to gin up interest in ID when we don’t really need more ID docs)? Or are we destined to face a critical shortage of ID specialists in the near future?

In my view, the answer depends upon answers to other questions that the current trainee has very little control over, including: (1) will the funding climate improve for physician scientists?, (2) will health care reimbursement in the U.S. eventually move fully from RVU-based to value-based?, (3) if the answer to question 2 is yes, how will that health care be delivered?, and (4) will ID physicians continue to play a major role in individual hospital quality-safety programs (e.g. infection prevention, antimicrobial stewardship), or will their roles be supplanted by hospitalists and other non-ID trained quality-safety experts?

Expanding on questions 2 and 3 above, I’ve often heard it said that value-based purchasing and the move away from RVU-driven reimbursement would be a boon to ID docs. I’m not so sure about that. Many areas of our rural state have no local ID expertise—as a result, our faculty field several calls per day from providers seeking (free) ID expertise, are now performing “eConsults”, and plans are for us to greatly expand our telehealth programs. These programs are designed not, as Petersdorf envisioned, to increase “referrals to teaching hospitals”, but instead are meant to reduce the need for these expensive referrals.

What is the least expensive way to provide ID expertise to a large population? Sadly, I envision a future “ID Command Center”: an advanced telehealth unit that allows one ID doc to provide consultative support to entire healthcare networks, providing instant access to all the required information….except for that which can be gained by actually touching the patient. Sorry, Abraham.

What do you all think?

Photo credit: Mike Staugaitis

Happy Friday - 21st Century ID Consults

Many of us went into ID because of the diagnostic challenges of complicated fever work-ups or the occasional excitement of a trop-med case. But we ended up here. Oh, is there a separate billing code for doing discharge summaries for other services?

And if you haven't read Harold Horowitz's NEJM Perspective on Fever of Too-Many Origins yet, it's well worth reading.

We're good enough, we're smart enough, and doggone it, people like us!

Today's daily affirmation for infectious diseases doctors comes to us from Dave Warren's group at Washington University and is published in this month's American Journal of Medicine. In this study, the authors evaluated 341 cases of Staph. aureus bacteremia and compared outcomes between those patients who had an infectious diseases consult and those who didn't. Not at all surprising to any of us was that in multivariable analysis, patients who had ID consults had a 56% reduction in 28-day all-cause mortality, even though by most metrics the patients who had the consults were sicker. So when you start your rounds tomorrow consider yourself an independent predictor of good outcomes!