HIV and ID Observations

Before getting to today’s main topic, allow me a brief protest — three recent vaccine-related actions that reek of profound (and misguided) vaccine distrust from HHS leadership.

They are:

• Cancellation of a grant to develop an H5N1 vaccine. Preparation for this looming pandemic threat is critical, and there’s arguably no better way than having a vaccine ready.
• Removal of pregnant women as eligible to get a COVID-19 vaccine. This, despite their inclusion in the recent FDA decision. The American College of Obstetricians and Gynecologists (ACOG) immediately protested.
• Ending a program developing an HIV vaccine. Just because something has been scientifically difficult, or has primary benefits in other countries, doesn’t mean the research agenda should be abandoned.

So painful.

(Deep breath.)

Ok, on with the main topic of today’s post. In Part 1 of this series, I described how ID doctors earn their income through direct patient care — consults, outpatient visits, and (less commonly) procedures. But clinical care is not the only source of salary support for our specialty. In this installment, I turn to the ways ID specialists support hospitals and healthcare systems. This work is often essential for optimal patient care but is frequently undervalued.

4. Agreements to provide critical hospital patient-care–related services. The most common are payments from hospitals to ID doctors to manage infection control and antibiotic stewardship programs, as these are required services in every hospital. Less often, an ID doctor might provide clinical advice (as a consultant) to the microbiology laboratory. For some ID doctors, these activities comprise a significant portion of their salary.

Similar agreements can sometimes be negotiated for other patient-specific activities — for example, at our hospital, we have payments to support care of patients with HIV (salary support is distributed to doctors, nurses, social workers), people with cancer- or transplant-related infections, and patients on outpatient parenteral antibiotic therapy (OPAT).

(For years, we did OPAT with no funding. I strongly advise anyone doing this now for free to do what we ultimately did — state you’ll stop providing this critical service unless it can be appropriately supported financially. Then set a date, and let the orthopedic surgeons, cardiologists, or whoever wants to discharge a patient on OPAT know they’ll be managing it themselves. If you’d like to read more about the hot potato of OPAT, I’ve got you covered.)

We used to have a contract to provide ID care and support for an affiliated community-based group practice, one owned by an HMO (remember those?). Two of us staffed a nearby clinic once a week, and just as importantly — since we weren’t on site full-time — we were funded to provide medical back up their outstanding nurses, who focused on ID/HIV care and fielded questions from our patients. I really enjoyed that work, especially the long-term patient relationships and collaboration with such a skilled nursing team. But when the HMO ended its affiliation with our hospital, the contract vanished too. Poof, decades of relationships, gone. Sometimes, the business side of medicine hurts.

5. Telehealth. Given the shortage of ID doctors, especially in rural areas, some hospital systems employ ID doctors to provide ID consultations remotely to affiliated hospitals, rehabilitation centers, and skilled nursing facilities. The consultations can take the form of telehealth consults directly with patients (with on-site providers giving more of the medical history), or clinician-to-clinician advice, with the caveat that the latter has little in the way of reliable billing options. (As I’ve noted a billion times. But who’s counting.)

Among academic medical centers, the University of Pittsburgh Medical Center (UPMC) was a leader in this telehealth activity — even before the pandemic — and two of our ID fellow graduates partially support their salary through this work. Notably, UPMC had a strong incentive to develop telehealth since their network extended far beyond the city of Pittsburgh. For both patient convenience and cost, it made more sense to pay ID doctors for telehealth than to put the patient in an ambulance and bring them to the main campus for care.

Outside of academic medicine, private companies offer telehealth services throughout the country and some provide ID-specific care — one notably started by an ID specialist, Dr. Javeed Siddiqui.

6. Travel clinics. Since insurance does not cover many travel-related vaccines, some ID doctors own or work in travel clinics that are cash-first businesses, catering exclusively to a self-paying (and usually well-to-do) clientele. To quote Dr. Ron Nahass, who is not part of one of these clinics, and how they fit in our healthcare system: “It is a consumer product, not a medical service.” An amazing but true fact — many of these clinics won’t do an evaluation of someone returning from travel with an illness, but refer them to ID clinicians like us!

Importantly, this revenue model does not apply to all travel clinics. Many ID doctors who specialize in travel medicine work in nonprofit settings and provide excellent and comprehensive pre- and post-travel services — including evaluations of travel-related infections. Unfortunately, in certain academic medical centers, it can be a struggle to make them work financially for a variety of arcane billing reasons. I’m aware that some have had to close based on losing money, despite the important and in-demand service they provide.

That wraps up Part 2 (after that painful vaccine news up top). As a consolation, here’s the promised dog video. Will Pepper get a call-up to the show this season?

In Part 3: infusion services, pharmacy programs, industry-sponsored trials, and other creative ways ID docs try to keep the lights on. Stay tuned.