Securing Our National Public Health Security With a Robust Infectious Disease and HIV Workforce
The microbe that felled one child in a distant continent yesterday, can reach yours today, and seed a global pandemic tomorrow.
-- J. Lederberg, 1958 Nobel Prize winner, 1988
ID Physicians on the Frontlines
Infectious Diseases physicians play critical roles throughout the health care and public health system. They work to prevent, diagnose, treat and conduct research on infections and serious conditions that affect us all and that know no geographical boundaries. ID is a diverse field with ID physicians leading efforts to respond to:
- emerging outbreaks, such as Zika, Chikungunya and Ebola;
- drug resistant infections, such as Methicillin-resistant Staphylococcus aureus (MRSA), Carbapenem-resistant Enterobacteriaceae (CRE) and multidrug-resistant gonorrhea;
- the urgent need for appropriately prescribing antibiotics to prevent drug resistance and Clostridium difficile infections;
- serious infections requiring ongoing care, including, HIV/AIDS and viral hepatitis;
- infections, in addition to HIV and hepatitis C, related to injection drug use, such as endocarditis and bacteremia; and
- infections associated with organ and tissue transplantation and chemotherapy.
The Value of ID and HIV Physicians
Patients with infections treated by ID physicians have better health outcomes and lower hospital costs with documented lower mortality and shorter stays for hospitalized patients. ID physicians and ID programs also are major providers of HIV care, and patients managed by physicians with HIV expertise have better health outcomes and lower health care costs. A recent study documented ID physicians account for the largest specialty represented among HIV providers and predicted that by 2019, HIV provider capacity will fall significantly short in meeting patient demand for HIV care.
ID and HIV physicians primarily provide comprehensive evaluation and management of patients with acute or chronic, often very serious, conditions as well as extensive counseling and ongoing care coordination. Current reimbursement methodologies undervalue evaluation and management services relative to procedural-based care. One study suggests that Medicare pays 3 to 5 times more for procedures than cognitive care when comparing reimbursement for two common procedures to reimbursement for comparable time spent on cognitive care services.
A Decline in Physician Interest in ID Training
Since 2011, there has been a steep decline in the number of physicians applying for ID program slots resulting in an increasing number of programs that do not fill through the National Residency Matching Program. In 2016, fewer than half of ID programs filled their fellowship position through the Match and more than one third of fellowship positions across programs went unfilled through the Match.
Factors Influencing the Decline
Studies indicate that a number of factors are deterring physicians' from entering infectious diseases. The two primary and related issues regularly identified by residents are lower salaries relative to other physician specialties and high debt burden from medical school.
The disincentive to enter ID is compounded by physician expectations that after investing in two to three years of additional training their remuneration will be lower than prior to specialization. Greater exposure to ID training, ID mentors and ID learning opportunities positively influence physician interest in ID.
IDSA and HIVMA Response
Concerned by a potentially crippling decline in ID and HIV workforce capacity, IDSA and HIVMA are taking action to attract the next generation of ID and HIV providers and support the current workforce. Highlights include:
- Sponsoring the IDSA Medical Scholars Program, HIVMA Medical Students Program and Clinical Fellowship Program;
- Supporting students and residents by offering special rates for membership and IDWeek, development of an IDWeek Mentorship Program and ID Interest Groups at medical schools (beginning fall 2016);
- Partnering with other cognitive specialties to have the value of non-procedural based health care services to patients, public health and the health care system recognized through payment reform;
- Educating ID and HIV physicians on quality improvement initiatives and developing ID-specific quality measures relevant to new payment models;
- Conducting a study of current and future ID workforce needs; and
- Documenting the value of ID/HIV specialists to patients and the health care system.
Federal Action Needed
Policy changes and educational/research support are necessary at the federal level to retain and grow an adequate ID and HIV medical workforce. In addition to the actions below, a national, independent evaluation conducted by the National Academies of Medicine with support from key stakeholders, including the federal government and private industry partners, is urgently needed to examine the issues affecting the specialty and recommendations for addressing them.
Administration -- Centers for Medicare and Medicaid Services
Administration/U.S. Congress -- Patient Care/Public Health
Administration/U.S. Congress -- Next Generation of Scientists/Researchers