Infectious diseases compensation in the USA: the relative value

Infectious diseases, as a subspecialty of internal medicine, has endured despite predictions that it would become irrelevant in the antibiotic era. In fact, following numerous worldwide health threats, including SARS-CoV-2, HIV, Zika virus, Ebola virus, multidrug resistant bacteria, and now monkeypox, the need for infectious disease physicians has never been more evident. Despite this need, infectious disease compensation in the USA has not kept pace with the value of ID physicians. Although health-care expenditure has risen steeply,¹ only a small portion of that increase goes to physician salaries, and among subspecialists, infectious disease physicians have seen the smallest increase in compensation. Infectious disease salaries rank among the five lowest paid specialties in health care.² The main driver of this compensation imbalance lies in the reimbursement of activities associated with health care, which is a fee-for-service model that is driven mainly by work relative value units (wRVUs). wRVUs are mainly generated by face-to-face encounters and procedures, although the generation of wRVUs is not balanced through the different encounter types. A high-complexity infectious disease consultation for an inpatient will take more than 1 h to complete, generating approximately 3–4 wRVUs, whereas reading electrocardiograms can generate approximately 12 wRVUs over the same timeframe. This example shows how the wRVU system puts non-procedural specialties at a substantial economic disadvantage. Lower compensation is one of the main reasons that fewer residents enter infectious disease fellowships than enter other internal medicine subspecialties, such as cardiology or gastroenterology. and why many infectious disease physicians suffer from burnout and leave the field.³

What added value does the infectious disease subspecialty contribute to deserve improved compensation? Infectious disease consultation has been shown to reduce in-hospital mortality by 19% and cost of stay by 41%.⁴ This effect can be most appreciated in examples of patients with Staphylococcus aureus bacteraemia, where infectious disease consultation results in a 30–47% reduction in mortality,5, 6, 7 and patients with Gram-negative bacteraemia, where early infectious disease consultation is associated with significant reduction in 30-day mortality.⁸ Another value of infectious disease physicians lies in diagnosing conditions as not infectious in nature. Overdiagnosis of lower extremity cellulitis, for example, has been estimated to cost US$195–515 million annually in avoidable health-care spending in the USA.⁹ Additionally, infectious disease physicians are instrumental in making crucial infectious diagnoses, such as epidural abscesses, where diagnostic delays lead to poor patient outcomes, some of which are borne out in malpractice lawsuits. If awarded, the average malpractice ruling stands at $5 million for each epidural abscess. Preventing a single lawsuit would pay the yearly salary of 25 infectious disease specialists at our institution! Moreover, the Centers for Medicare and Medicaid Services penalise readmissions and hospital-acquired infections by withholding reimbursement.¹⁰ Many studies have shown improved use of antimicrobials and decreased incidence of health-care-associated infections as a result of antimicrobial stewardship and infection prevention programmes that are led by infectious disease physicians.¹⁰ One study showed a 50% decrease in rates of health-care-associated infection, preventing up to 105 deaths in a 7-year period.¹⁰ Although these efforts affect individual patients, services provided by infectious disease physicians have societal benefits that extend beyond the individual patient. Antibiotic stewardship efforts, resulting in the reduction of antibiotic resistance, affect the continuum of care from community to clinic and hospital to long-term care facilities. Infectious disease physicians provide crucial population-based leadership for infectious disease outbreaks and adherence to protocol guidelines.

The current compensation model can be compared with a bucket being filled by revenue from wRVUs generated by health-care services. Specialties with a heavy procedural element substantially contribute to filling the bucket, and thus garner a larger portion of the gains. Non-procedural clinical activities are central to preventing economic losses, in essence patching holes in the bucket. This prevention is a difficult metric to measure, but one that should be assessed to allow those specialists to share in the savings that their activities conserve. To achieve the goal of a fair market, and since it is not possible to capture the true value of the infectious disease specialty with wRVUs, infectious disease compensation should be decoupled from wRVUs. Value-based compensation, or even shared savings policies, should be introduced. As in all areas, a one-size-fits-all approach is seldom the answer, and physician compensation should not be different. It is time to realise that the current compensation model puts non-procedural specialties at a perilous disadvantage, and now is the time to make meaningful changes.

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GEH consults for Guidepoint International. All other authors declare no competing interests.