The real reason ID docs are the lowest paid physicians: AMA's Relative Value Scale Update Committee

In keeping with our annual tradition, Dan recently posted on the declining interest in ID fellowship slots filled through the match. Re-reading his 2013 and 2014 posts, it's quite clear things have not improved. It's also clear that IDSA takes the decline very seriously. In fact, two IDSA presidents, Dr. Stephen Calderwood and Dr. Johan Bakken, have taken time to post IDSA's diagnosis and responses to the public health problem. Both described the relatively poor compensation provided for ID services.

Quoting Dr Bakken: "There is no question in my mind that the financial student loan burden and inadequate reimbursement for ID services are major disincentives for young physicians contemplating a career in ID. IDSA alone does not have the power or means to rectify the problem, but we are working very hard with legislators and policy makers on Capitol Hill."

Without getting too much into the weeds, I wanted to share with you why I think Infectious Diseases is so poorly reimbursed compared to every other subspecialty. The reason is as old as politics - we have no representation on the AMA's Relative Value Scale Update Committee (RUC). Since 1991, CMS has collected advice from this AMA Committee on how much "physician work" is involved in delivering a particular service. This committee is important, since CMS agrees with the committee's recommendations almost 90% of the time. And as you can see in the figure I posted below, there is unequal and unfair representation on this committee. Some specialties are under-represented based on the number of services they provide (i.e. primary care) and certain medical subspecialties (e.g. nephrology, hematology) are only represented on a rotating basis while others (e.g. cardiology) have a permanent seat. Looking closely at the list of subspecialties, I don't see any Infectious Diseases representation!

So, if we want to fix ID, we need permanent representation on this committee. It is a complete travesty that the highly reimbursed procedure-focused subspecialties are fully represented but the "cognitive" subspecialties (endocrinology, ID, rheumatology) are invisible. IDSA needs to demand equal and fair representation.


  1. Critically important. Phil Lederer

  2. This is news to a young ID practitioner such as myself. I agree with you. Thanks for looking into this.

  3. Just wanted to correct some misinformation. IDSA has been represented at the RUC by Dr. Larry Martinelli since 2004 and by myself since 2008. Membership on the RUC panel was determined years ago by criteria including amount of Medicare PFS billing by specialties and whether they were ABMS specialties (ID is not). Aside from the addition of primary care and geriatrics seats a couple of years ago the panel composition has not changed. We, as IDSA Advisors, attend every RUC Meeting and participate in discussions fully in discussions. In fact, Dr. Martinelli has been elected to 2 terms as a RUC Member Panelist via one of ACP's rotating seats (elected from ID, Endocrine, Rheumatology, Hem-Onc). Dr. Martinelli was one of the key leaders who secured valuation for office infusion codes our members use daily as part of office-based OPAT programs and also as part of the ACP group that gained increases in RVU value for all E&M codes several years ago. He was also recognized with an IDSA Citation for his work. Dr. Steve Schmitt represents ID at the AMA CPT committee.

    The real problem is not the RUC panel per se, it is the Resource Based Relative Value System (the 'R' in RUC) which assigns a higher RVU value to procedural activities to account for the costs of site of service, equipment and supplies. Those inputs are far lower for E&M services resulting in the disparity in payment.

    We participate with a coalition of like cognitive specialties, at CPT-RUC, at CMS, and on Capitol Hill, as part of larger efforts to reform the payment system. CMS' anticipated condition of participation requiring hospitals to have physician led ASPs should switch the negotiation with hospitals for those services from bean-counting savings to support for the value we provide the hospital/ACO/system in quality, safety and outcomes.

    In short, some of us have been working very hard on your behalf for quite some time in large part to due to IDSA leadership recognizing that we really do need a seat at the table. Be assured there our voices in the process are heard and respected. We welcome your effort to advance the cause.

    1. So to clarify, ID does not have a permanent seat at the table but occasionally rotates with three other subspecialities? That was the point of my post. I wasn't discounting the progress made by you and Larry just suggesting we need a permanent seat. And the proof is that we have the lowest salary and this is translating into limited interest in ID fellowships. Thanks for your comments.

  4. Eli: I get that, but your readers could be left with the impression ID has no voice at all, hence my post. It would be great to have a permanent seat but that is neither going to happen nor would it correct the system's valuation flaw that rewards proceduralists because of higher resource costs.


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