Infectious diseases (ID) physicians may be disappearing. In the 2016 internal medicine fellowship match, in which residents were matched with sub-specialty training programs, 35 percent of available ID training positions nationwide were left unfilled. By comparison, just 0.9 percent of gastroenterology and cardiology positions were not filled that year (Figure 1). Although trainees' career choices are influenced by many complex factors, the driving force behind residents' aversion to ID is likely quite simple: money.
ID specialists are among the lowest paid physicians in the United States. According to the 2016 Medscape Physician Compensation Report, the average ID physician earns $215,000 per year, while the average incomes in gastroenterology and cardiology are almost double that, at $380,000 and $410,000 respectively. The average salary in ID is also lower than that of hospitalists, who are not required to complete additional years of training beyond residency.
Calculating An ID Physician's Value Is Not A Straightforward Equation
A common explanation for the lower compensation of ID physicians is that they create less revenue than their peers create and therefore contribute less value to the health care system. Admittedly, within a fee-for-service system ID physicians do generate fewer "relative value units" (RVUs) than many other specialists. A RVU is a numerical quantity assigned to each physician visit or procedure that is used to determine compensation. This system typically assigns a greater monetary value to surgeries or other invasive procedures than to care that does not involve a procedure, regardless of how specialized or demanding that care may be. As specialists who perform almost no procedures, ID physicians' ability to generate RVUs is therefore limited.
However, while ID specialists may create relatively few RVUs, several recent studies have shown that their work is associated not only with improved patient outcomes, but also reduced costs. For example, one review of inpatient Medicare claims data showed that patients seen by ID consultants had lower mortality rates and were less likely to be readmitted when compared to matched controls. This enviable combination of better outcomes for lower costs is often considered the very definition of "value" in health care.
The value generated by ID consultants may be, at times, difficult to quantify. Although their billing receipts may be modest, ID physicians may create value by pursuing a sensible diagnostic workup and avoiding unnecessary tests. They may encourage the judicious use of antimicrobials, thereby limiting the administration of expensive medications while also preventing the costly harms of antibiotic overuse, such as Clostridium difficile infection. Often an ID consultant's role is simply to determine that there is no infection present at all, and to stop antibiotics. These functions suggest that, while many physicians are rewarded for doing more, much of an ID consultant's value may actually derive from doing less.
In addition to preventing the overuse of health care resources, ID physicians generate value by promoting safe and appropriate care for those who truly need it. For example, in patients with Staphylococcus aureus bloodstream infections, the involvement of ID physicians has been associated with lower mortality rates, shorter hospital stays, and better adherence to quality measures. Furthermore, when patients are discharged from the hospital to continue intravenous antibiotics at home, ID consultants can take ownership of their parenteral antibiotic therapy and provide reassuring continuity between the inpatient and outpatient settings. In this role ID doctors further help to prevent readmissions and provide high-quality continuous care for high-risk patients.
ID specialists also create value though non-clinical duties, such as directing antimicrobial stewardship and infection control programs. As antimicrobial stewards, they help to limit the costs and harms of antibiotic misuse on an institutional level. And as hospital epidemiologists, they work to track and prevent the spread of hospital-acquired infections, protecting not only patients but also health care workers and staff. The rising prevalence of multidrug-resistant bacteria and the emergence of new pathogens such as Ebola underscore the importance of this work.
New Payment Models Could Improve ID Physicians' Compensation
Despite their valuable contributions to the health care system, ID physicians remain relatively underpaid, and the field struggles to compete with more lucrative specialties when recruiting medical trainees. As medical school tuitions continue to rise and many students face the prospect of repaying hundreds of thousands of dollars in educational loans, the pool of qualified trainees entering ID seems to be quickly dissipating.
To prevent the disappearance of ID specialists and encourage more trainees to enter the field, the basis of ID physicians' income must change to better reward their ability to generate value that is not easily captured by RVUs. This change would also benefit other fields that are similarly underpaid for their cost-saving effects. For example, an internist who helps a patient quit smoking, or a palliative medicine physician providing end-of-life care, may improve outcomes and reduce utilization, yet they typically would not share in the savings that their work creates.
Coming changes to Medicare reimbursement, such as the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs) are encouraging shifts towards rewarding quality in health care over quantity. However, these programs seem unlikely to increase salaries in ID or other relatively underpaid fields unless hospitals, physician groups, and health care systems use the funds generated by these models to directly improve compensation.
The APM approach, in particular, is well suited to allow for this type of redistribution of revenue to doctors that generate value. APMs are intended to give organizations greater control over how care is delivered, to incentivize high-value medicine, and to allow providers to share in some of the savings that they produce. Groups that join APMs could therefore dedicate some of the savings generated by ID consultants to directly improving the pay of those physicians. If enacted on a large scale, this simple intervention would likely help draw students and residents back towards careers in ID.
Recent ID fellowship match rates suggest that economic forces are driving young doctors away from a specialty that improves outcomes, promotes the safety of patients and staff, and ultimately saves the health care system money. To reverse this trend and attract more talented young physicians to this field, ID consultants must be better compensated for their ability to generate value while not necessarily generating RVUs. Recent changes to Medicare reimbursement policy represent an opportunity to reconsider how ID specialists are paid, and to invest in the future of high-value care.
Figure 1: Percent of available US fellowship positions matched in infectious diseases, gastroenterology and cardiology, 2012-2016
Percent of available US fellowship positions matched in infectious diseases, gastroenterology, and cardiology, 2012-2016. ID=infectious disease. GI=gastroenterology.
Data adapted from the National Resident Matching Program 2016 Results and Data
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