HIV and ID Observations

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If you’ve made it this far, congratulations! You’re now deep into the ID Reimbursement Rabbit Hole. Part 1 and Part 2 covered how ID doctors contribute immense value through patient care, stewardship, infection control, travel clinics — proudly fighting along the way for appropriate compensation as the “Loss Leaders” of the hospital.

(Did you get your emblazoned fleece vest yet?)

Before going on, however, I’d like to address the ongoing concern that discussing payment is somehow unseemly. That discomfort with discussing money is understandable — especially given the bloated costs of American healthcare and our field’s patient-centered mission, with care often delivered to people who are disenfranchised or stigmatized.

As a result, it’s very “on brand” for ID in particular to avoid these discussions. As my colleague Dr. Daniel Solomon put it when I floated the idea for this series:

It is tough to talk about money in some crowds. Especially (paradoxically) some ID communities. As much as I love our field, there is an overrepresentation of people in ID who seem to judge such discussions harshly.

Yep. But in defense, if we don’t talk about it, how can we expect things to change? Very much appreciate Dr. Alice Han’s comment in response to Part 2.

So let’s wrap up with Act 3 of the show, a miscellaneous grab bag of other areas for salary support.

7. Infusion services. Free-standing ID practices can offer infusion services, where patients can receive intravenous dalbavancin or daptomycin or remdesivir or you-name-it. Of course, this takes up-front investment in clinic infrastructure, deft administrative support to obtain prior approvals for expensive drugs, as well as purchasing and storing the medications. I’ve furthermore heard that the revenue is tightly tied to the cost of the drugs (dropping for many IV antimicrobial agents as they go generic) and the quality of a patient’s insurance.

Still, one ID doctor reached out to me a to share how much his patients appreciated the service — and how profitable it was for the practice. Even with declining drug margins, his nimble outpatient ID group leveraged infusion services to reduce hospitalizations and ED visits, which payers (and patients) appreciated, the former paying them to keep it afloat.

But if, like me, you work at a hospital, the outpatient infusion center is run by the institution. Most of their treatments are regularly scheduled immunosuppressants (for rheumatology, GI, neurology, etc.), chemotherapy (if a cancer center), and immunoglobulins. We occasionally bug* them for outpatient parenteral antibiotics, but none of the revenue flows back to the ID doctors.

(*See what I did there?)

8. Pharmacy. If a clinic or hospital provides “safety net” care to a sufficient proportion of people, they may be eligible to participate in the 340B pharmacy program. This allows pharmacies to purchase the medications at a discounted price, but charge the usual price to payers, with the difference set aside to cover the care of patients who are socially or financially disadvantaged.

For ID clinics that care for large numbers of people with HIV and have an affiliated pharmacy, the 340B program can be a financial savior. In fact, for some clinics, it’s their largest source of revenue, supporting not only ID physician salaries but also nursing, pharmacy, and case management.

Unfortunately, this isn’t universally true. Some institutions retain all 340B revenue (while simultaneously claiming that the ID clinic is a “cost center” — ouch!), with none of it going to ID. That’s … not what the program was designed for.

(Brief aside — did you know that the 340b program may be partially responsible for the ongoing high price of HIV drugs? Think about it — the higher the price, the bigger the net return for a 340b pharmacy, hence there’s an incentive to keep the prices high. It’s hard to find something in our bizarre American healthcare system that surprises people from other countries, but when I told them about this aspect of the 340b program, it certainly caused some head scratching.)

9. Industry-sponsored clinical trials. I originally intended to leave all research activities off this guide of how ID doctors get paid, as it felt more related to academic medicine in general rather than ID in particular. After all, successful physician researchers often have grants that cover 80% or more of their salary.

But Ron Nahass pointed out to me that industry-funded clinical trials are different; they’re available to a broader range clinical ID doctors who would only consider themselves part-time investigators at most. They also pay per enrolled participant, not for protected time. Note that companies running these trials often look outside of academic medical centers for their highest-enrolling sites, and also appreciate what is usually a more efficient processing of contracts and other paperwork.

So, briefly: for practices with the infrastructure to support them, industry-sponsored trials can both benefit patients and generate income to support ID clinicians. Trials can offer access to novel treatments, cover travel and parking, and even provide stipends to compensate patients for their time. For some patients, participating is also a way to “give back” to a specialty that has helped them, or because they’d like to play a role in advancing the field. It is amazing — and quite humbling — how altruistic some people are about signing up for research studies solely for this reason.

So that covers some of the major sources of salary for US-based ID doctors, leaving aside support they might get from research grants, teaching at an affiliated medical school, or administrative roles. For more reading on this topic, here’s a link to this remarkable Reddit thread from the residency subreddit about choosing ID as a specialty, which I found fascinating:

What's the deal with ID
byu/tophatcat4 inResidency

To sum up the comments: we don’t go into ID for the riches — but we love what we do!

Last dog video (of the series):

What an impressive jumper! I love how calm Sounders is when being “interviewed” on camera between jumps