美國傳染病補償:相對價值
資料來源:www.thelancet.com/infection Vol 22 August 2022 / 財團法人台灣紅絲帶基金會編譯
感染科作為內科的一個亞專業,儘管預測它在抗生素時代將變得無關緊要,但它仍然存在。事實上,繼 SARS CoV-2、HIV、玆卡病毒、伊波拉病毒、耐多藥細菌和現在的猴痘等眾多全球健康威脅之後,對感染科醫生的需求從未如此明顯。儘管有這種需求,但美國的傳染病補償並沒有跟上感染科醫生的價值。儘管醫療保健支出急劇增加,但其中只有一小部分用於醫生工資,在專科醫師中,感染科醫生的薪酬增幅最小。感染科工資位居醫療保健行業薪酬最低的五個專業之列。這種薪酬不平衡的主要驅動因素在於與醫療保健相關的活動的報銷,這是一種主要由工作相對價值驅動的按服務收費模式單位(work relative value units, wRVU)。 wRVUs 主要由面對面的相遇(看診)和程序產生,儘管 wRVUs 的產生在不同的相遇類型中並不平衡。住院患者的高複雜性傳染病諮詢需要 1 小時以上才能完成,產生大約 3-4 個 wRVU,而判讀心電圖可以在同一時間範圍內產生大約 12 個 wRVU。這個例子顯示了 wRVU 系統如何將非程序性專業置於嚴重的經濟劣勢。較低的薪酬是進入感染科學習領域的住院醫師少於進入其他內科醫學亞專業(如心臟病學或胃腸病學)的主要原因之一;以及為什麼許多感染科醫生會因為倦怠而離開這個領域。
感染科亞專業有哪些附加值值得提高補償?傳染病諮詢已顯示可將院內死亡率降低 19%,住院費用降低 41%。這種效果在金黃色葡萄球菌菌血症患者的例子中最為明顯,其中傳染病諮詢導致 30-47%死亡率降低,以及在革蘭氏陰性菌菌血症患者,其中早期傳染病諮詢與 30 天死亡率顯著降低有關。感染科醫生的另一個價值在於診斷疾病本質上不是傳染性的。例如,據估計,在美國,下肢蜂窩織炎的過度診斷每年會花費 1.95 至 5.15 億美元用於可避免的醫療保健支出。此外,傳染病醫生在進行重要的傳染病診斷方面發揮了重要作用,例如硬膜外膿腫,診斷延誤導致患者預後不佳,其中一些在醫療事故訴訟中得到證實。如果獲得裁決,每個硬膜外膿腫的平均醫療事故裁決為 500 萬美元。 杜絕一場官司,可支付本機稱25名傳染病專家的年薪!此外,醫療保險和醫療補助服務中心透過拒絕報銷來懲罰再入院和院內感染。許多研究顯示,由於抗菌藥物管理和感染預防計畫的實施,抗菌藥物的使用得到改善,與醫療保健相關的感染發生率降低,由感染科醫生所領導。一項研究顯示,與醫療保健相關的感染率降低了 50%,在 7 年內避免了多達 105 人死亡。儘管這些努力影響到個別患者,但傳染病提供的服務醫生的社會利益超出了個體患者的範圍。導致抗生素耐藥性降低的抗生素管理工作,影響了從社區到診所、醫院到長期照護機構的連續性照護。感染科醫生為傳染病爆發和遵守協議指引提供基於人群的重要領導。
當前的補償模式是與醫療保健服務產生的 wRVU 的收入相提並論。具有繁重程序元素的專業極大地有助於填充收益桶,因此獲得更大部分的收益。非程序性臨床活動是防止經濟損失的核心,本質上是修補收益桶漏洞。這種預防是一個難以衡量的指標,但應該對其進行評估,以使這些專家能夠分享他們的活動所節省的成本。為了實現公平市場的目標,由於無法透過 wRVU 捕捉傳染病專業的真正價值,因此應將傳染病補償與 wRVU 脫鉤。應該引入基於價值的補償,甚至共享節省經費之政策。與所有領域一樣,一刀切的方法很少是答案,醫生的補償也不應該有所不同。是時候意識到當前的薪酬模式將非程序性專業置於危險的劣勢,現在是做出有意義改變的時候了。
GEH 為 Guidepoint International 提供諮詢。
所有其他作者聲明沒有競爭利益。
Guy El Helou, Amy Vittor, *Ammara Mushtaq, Denise Schain mushtaqa@ufl.edu
佛羅里達大學醫學系傳染病和全球醫學部,美國佛羅里達州蓋恩斯維爾 32610
Infectious diseases compensation in the USA: the relative value
www.thelancet.com/infection Vol 22 August 2022
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 SARSCoV-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, 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. 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.
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%. 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, and patients with Gram-negative bacteraemia, where early infectious disease consultation is associated with significant reduction in 30-day mortality. 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. 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. 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. One study showed a 50% decrease in rates of health-care-associated infection, preventing up to 105 deaths in a 7-year period. 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.
GEH consults for Guidepoint International.
All other authors declare no competing interests.
Guy El Helou, Amy Vittor, *Ammara Mushtaq, Denise Schain mushtaqa@ufl.edu Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA