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:

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.

National Residency Matching Program statistics
Infectious Diseases Society of America

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

  • Re-evaluate reimbursement methodologies for ID and other specialists that provide comprehensive evaluation and management services to patients with complex medical conditions.
  • Support development and implementation of ID-specific quality measures to allow ID physicians to benefit from new payment models.
  • Apply appropriate risk adjustment for sociodemographic factors to quality measures.
  • Ensure appropriate distribution of shared savings achieved through alternative payment models for ID and HIV physicians and other non-procedure based specialties.

Administration/U.S. Congress -- Patient Care/Public Health

  • Increase payment rates for cognitive services (evaluation and management services) under Medicaid and Medicare.
  • Pass the HIV Clinical Services Improvement Act (S. 2097 and H.R. 3637) to better align Medicaid reimbursement for HIV care with the cost of care for patients in Ryan White-funded clinics.
  • Increase compensation and simplify requirements for non-clinical services, such as care coordination, antibiotic stewardship, consultative medical chart review and other activities important to improving individual and population health outcomes and to reducing health care costs.
  • Provide loan repayment and loan forgiveness opportunities to ID and HIV physicians managing medically underserved patient populations, including those affected by hepatitis C, HIV and the opioid epidemic and those responding to other public health emergencies.
  • Sustain federal programs critical to HIV and ID, including the NIH, CDC, AHRQ and the Ryan White Program.

Administration/U.S. Congress -- Next Generation of Scientists/Researchers

  • Expand funding for NIH loan repayment programs and increase the loan forgiveness amount to more accurately reflect the debt burden of training.
  • Increase the pay scale of NIH Career Development (K) awards or provide other federal funding options for the training of physician scientists.
  • Explore novel pilot approaches to increase the award rate for new investigators.
  • Establish a new physician-scientist grant mechanism to facilitate the transition from K to R level awards.
  • Explore opportunities for public private partnerships to support ID and HIV research.
  • Explore removing eligibility restrictions on T32 training grants that limit them to U.S. citizens and permanent residents.