We work hard for the money pt.1: thinking creatively about ID reimbursement

Buddy Creech: [00:00:12] Hi, everybody. I'm Buddy Creech and this is Let's Talk ID. For years, PIDS and IDSA have been sounding the alarm that the ID workforce is insufficient to meet the needs of children and adults with complex medical conditions. Unfortunately, the pipeline for ID is not encouraging. It's only about 50% of adult and pediatric fellowship positions are filled each year. A key driver of this weakened pipeline is the financial impact of working in a non-procedural specialty such as ours. For example, to make the decision to forego a career in general pediatrics financially neutral, a resident entering fellowship training in pediatric ID would need to receive a lump sum payment of $1.5 million. So for that reason, we're taking the next two episodes of Let's Talk ID to peel back the curtain on health care finance. In this first episode, I'll talk with Nancy-Ann DeParle and Gabe Roberts, leaders in health care finance and implementation, who have expertise in both the public and private sectors. And in the second episode, I'll talk with IDSA past President Dan McQuillan, who has spent countless hours over many years advocating for infectious diseases providers at the highest levels. Now, there's one important caveat as we start. While IDSA and PIDS efforts to address compensation issues are not new, it has taken a while to have the type of seat at the table that's needed. Our conversations will span three decades. Therefore, some of the issues that affected ID in the late 90s or early 2000s, these were addressed years ago. Admittedly, other issues still exist, but we really can applaud the persistence and dedication that our colleagues have shown to get us to the place that we are now. We've come a really long way and that should give us all hope that we're well positioned at the highest of levels to address this fundamental crisis in infectious diseases.

Buddy Creech: [00:01:57] Now on to the first episode. Nancy Ann and Gabe, I'm so thankful that you've joined me today on Let's Talk ID. I can't possibly do your introductions justice, but I want to at least hit the highlights for each of you. Nancy-Ann DeParle is a managing partner and co-founder of Consonance Capital Partners. She's a director of CVS Health and HCA Healthcare, was recently elected to the Duke University Board of Trustees and is a member of the National Academy of Medicine. From 1997 to 2000, DeParle served as administrator of the Health Care Financing Administration, which is now CMS. And from 2011 to 2013, she was assistant to the president and deputy chief of staff for policy to President Obama. She led the Obama administration's efforts to enact the Affordable Care Act, and she managed the initial implementation of the law. Joining her is Gabe Roberts, who's founder and CEO of Roberts Consulting Group, a national strategic advisory firm. Prior to founding RCG, Roberts spent seven years at the Tennessee Medicaid Agency, including serving as its director for the last year and a half of his tenure. During his time at TennCare, Gabe served on the board of directors of the National Association of Medicaid Directors, was named a fellow with the Medicaid Leadership Institute and a fellow with the Nashville Health Care Council. A sincere welcome to you both. I want to start our discussion by thinking about compensation for Non-procedural specialists who are paid very differently than proceduralists. Nancy-Ann, I'd like to start with you. Can can you walk us through just some of the basic tenets of compensation and reimbursement at a macro level?

Nancy-Ann: [00:03:26] So you mentioned that I started at HFA. So when I started is when the physician fee schedule, the original RBRBS, had just been in place for a few years and it was reformed then. Of course it's been reformed recently, but that is the mechanism for compensation of physicians through Medicare and the one that other payers often use as well. And it's the thing that seems to be so focused on procedures and of course it's set up to work with this thing called the RUC, which is the committee of the AMA that looks at, in a zero sum fashion, physician compensation and decides, well, is there something about the work of oncologists that has increased and therefore we need to increase their weight and if they increase one specialty's weight, another one has to go down? My sense is that infectious disease specialists have kind of been behind the gate on this thing. They have not been, I don't know who sits from that specialty on the RUC. AI don't want to throw them under the bus. I'm sure they're doing their best. The good news is that it took probably ten years or more, but internal medicine made that case starting back in the 90s, 80s. It took some time, but finally members of Congress started to say, you know, they're right. We're not properly valuing the work that people who are in internal medicine do and starting to put some focus on it and started to try to weight it differently, which is how this more recent physician fee schedule is supposed to work. It's not ideal. Now is the time to start getting educated about it and start working as a group and your various associations to. try to make a difference in that. At the AMA, with CMS and with Congress as well. If there were ever a time when the value of an infectious disease clinicians should be really obvious to all of us, it's right now in the wake of this pandemic.

Buddy Creech: [00:05:24] I think that's really helpful. IDSA and PIDS alike have been working in this space for many years. And I think one of the challenges has been that it's not always clear how to assign value to some of the historically non-billable activities that we do. And Gabe, I wonder if you have some thoughts about this, about, you know, how do we capture well, how do we capture value, how do we capture what an ID physician, an ID provider, what that value is to a health care system, to an individual patient or to a society?

Gabe Roberts: [00:05:59] Right. So my bias will be coming at this from a Medicaid-informed perspective. And on top of that, a managed care Medicaid-informed perspective, where we value, above all else, true health outcomes and health value. And it may be more expensive on the front end, but we bet on the long term. That's what we do in Tennessee Medicaid. And so when I think through how you capture that value, I always kind of think about it in terms of tradeoffs. And maybe to start in a particular level, we think about a quote unquote traditional payer provider negotiation and we try to understand what is the intervention the provider or group of providers is providing and what is the overall value to the system. Now that can be defined in a bunch of different ways, as you know. But one of the ones that a lot of us on the payer side like to lean on or gravitate towards is how much long-term cost can you take out of reducing the system because you've improved the life with best in class care, for example, Can you avoid a readmission? Can you diagnose a chronic condition early and get that managed under control? Et cetera. Et cetera. And so then from that perspective, while it certainly isn't easy, you can then work backwards to figure out how much value needs to then be shared between the ultimate payer and the individual or group of individuals who are actually making the intervention.

Gabe Roberts: [00:07:23] Think in a situation like what we've been talking about before, how do you go and in one breath say, We know that it's undisputable that our ID provider group and community provides unbelievable and absolutely critical value to us and in the same breath say, and so we're going to prove all the terrible things they help us avoid, Right?

Nancy-Ann: [00:07:47] Right.

Gabe Roberts: [00:07:47 So that construct, that I kind of like leaned on is not necessarily the best one to talk through. Two thoughts. One is to kind of maybe try to take a value-based payment model and try to think about different sources of value that aren't necessarily related to better health outcomes as a proxy for reduced cost or vice versa. And then secondly, is there a societal value that we can place on trying to stymie where it looks like we might be going with unfilled residencies, lower compensation? Et cetera. Et cetera. That might make the policy case for national and state policymakers to come together and try to create a tipping point of sorts of making some upfront investments into that provider space so that we won't hit some huge critical problem the next time, or if there is another global outbreak, a pandemic. Et cetera, that hits within like two weeks, Right?

Nancy-Ann: [00:08:50] Right. When there is. Maybe these aren't infectious disease specialists I'm listening to, but I keep hearing that. So, Dr. Fauci, if you're listening, I think Gabe's idea would be a good one for you in retirement. [laughs] to take up that take up that baton?

Buddy Creech: [00:09:04] I love it.

Nancy-Ann: [00:09:05] But, you know, Gabe, when you said that I'm sitting here in my mind trying to design a model to go to the innovation center and say, let's try this. The issue I have, I like what you're designing. I can see the payer saying, okay, I have a population in Tennessee. Let's say it's United Health care. I have I have a population in Tennessee of Medicaid patients that I'm responsible for who have signed up with me. And I'm willing to pay someone to keep them out of the hospital. Several someones. Who sits on the other side of that, though, Gabe? That's the problem.

Gabe Roberts: [00:09:39] Right.

Nancy-Ann: [00:09:39] Is it Buddy? Is it some individual doc in the community? I mean, what's happened typically, I'm asking that rhetorically because, you know, the answer, what's happened typically is it's Vanderbilt University Medical Center or some large thing, and maybe you could form an ACO around this, but I just don't know. I'm looking...maybe we're burdened by both being lawyers, but I'm looking for someone. I'm looking for someone on the other side of the contract. [laughs]

Gabe Roberts: [00:10:06] There's certainly a lot of burdens that we carry from being a lawyer. [laughs] That's one of them. Yeah, I mean, that's exactly right. And one thing I would say perhaps jumping ahead, Buddy, is that and maybe this is a point of vulnerability for me, but, you know, I think it would be unfair to assume if you were a society that was going to talk to policymakers, at least on the Medicaid side, it would be unfair to assume that those Medicaid policymakers in particular are going to understand the difference between the health system and a subgroup of specialists. And even if they did get that understanding, the reimbursement differences between, you know, ID docs and cancer docs. Clearly, I'm not suggesting that they don't know what's going on in the health care system, but it's very complex. And unfortunately, a lot of times policymakers, at least at the state level, you're tasked with not only setting trajectories and doing the things you need to do, but also responding and putting out a bunch of fires at the same time.

Buddy Creech: [00:11:05] Exactly.

Gabe Roberts: [00:11:06] So there's this element of this almost like a frustrated thinker problem, where I wish I had enough bandwidth to sit back and think through critically some of these areas so that we can proactively plan and avoid issues. And Nancy, I don't know if you feel that way at all or if you may disagree, but that's my thought from the state perspective.

Nancy-Ann: [00:11:26] I do agree, and I'm going to say more bluntly, a version of what you just said. So two things, putting back on my former policymaker hat. Number one, gentle listeners, cover your ears if you don't want to hear this, but in my years running Medicare at the Office of Management and Budget and at the White House, I don't believe I ever sat across the table from an infectious disease specialist arguing that their reimbursement was too low.

Buddy Creech: [00:11:56] And that's a problem.

Nancy-Ann: [00:11:57] It is a problem. Now, did I know some. Yes, Dr. Fauci, I was teasing about mentioning Tony a few minutes ago, but there are some who I know who've worked in government mostly. But as far as that conversation about, hey, the RUC screwed us over and my reimbursement is too low, I didn't have that. I had it with ASCO, the oncologists, I had it with the American College of Cardiology. I had it with the surgeons. I had it with radiologists. You know, pretty much every other group from time to time. Never had it with, I mean, you guys are too busy with your...

Buddy Creech: [00:12:32] putting out fires or pandemics. [laughs]

Nancy-Ann: [00:12:33] ..yes, looking through microscopes and figuring out what's coming down the pike. So that's number one. Number two, Gabe alluded to it and so did you. Is the problem with how do you prove the epidemic that didn't occur? You know, the thing that didn't happen to us, it isn't just a theoretical problem. It's more than that in government, at least from the federal side. Anything you decide you want to do has to be scored. I'm doing air quotes, by the Congressional Budget Office, but here's the good news. Until recently, they would not score prevention. So if you said we're going to invest in giving Tennessee more dollars to protect against STDs, and as a result, there'll be fewer kids getting mad and these benefits and we'll have savings in ten years. And some of that will be at the state level and some of the federal they'd be. Yeah, yeah, yeah, yeah, right. You're just increasing spending, forget it. Or, you know, come up with the tax dollars to pay for it. They've opened a window a little bit with respect to prescription drugs, at least in a study they did almost ten years ago now saying actually the Medicare drug benefit does appear to have saved money, kept some people out of the hospital, having a source to provide prescription drugs. I was part of a study group at Aspen that just did a report recommending that they do more on this. But right now, we're kind of nowhere. They do not really score prevention. So that's another way in which infectious disease specialists are a little bit behind the eight ball because  it's harder to show the..

Buddy Creech: [00:14:09] The bad thing that didn't happen. I agree.

Nancy-Ann: [00:14:12] The bad thing that didn't happen that you prevented.

Buddy Creech: [00:14:13] So this is really interesting. So this is exactly what I was hoping for in this conversation because very few of us in medicine have MBAs or very few of us really understand the policy and financial implications of a health care system that we could debate the elements of until we're blue in the face. But here are some random thoughts. One is, thankfully, IDSA has been at that table trying to have meetings not only at the highest of levels, but also trying to take a grassroots approach with our own congressmen and congresswomen, with our own health care systems, and really having a multi-pronged approach to saying, let's at least get the easy stuff right. And the easy stuff might be things like at the health care system saying we have very nice, consistent data that if you have certain types of infections, you do better as a patient if ID is called earlier rather than late, you get a better antibiotic, you have fewer side effects. The overall cost is better. And oh, by the way, you don't die. Like it's a really good outcome. If we're called early for, let's say, a bacterial infection of the bloodstream. We also recognize, though, that I'm really going to key in on this a little bit more about how do we measure those things that are either system based, like many of us work in the world of stewardship, where we're going through the health care system saying it would be better to use antibiotic A rather than antibiotic B, because antibiotic B is going to put too much pressure on the microbes that we all carry on our skin and in our gut.

Buddy Creech: [00:15:50]  And that's going to lead to some problems down the road. So we're going to use the right antibiotic at the right dose and the right patient for the right infection, for the right length of time. That isn't tied to an individual patient. So it's not like I'm putting down a code for an encounter or the fact that I spend 2 or 3 or four hours investigating the absolute best therapy for a complicated patient. And I talk with colleagues around the country to figure out what I should do. Well, that doesn't always get captured in our current setup, so how can we think creatively? Gabe, I might ask you first, how do you have ideas on how we think creatively about those either unmeasurable or unbelievable? Maybe they're measurable, but they're unbelievable activities that were really frequently engaged in.

Gabe Roberts: [00:16:39] Yeah, I mean, I feel like we could probably come up with a handful of back of the envelope scrolls now in the conversation, if you think about in certain areas, OUD, some of the IDD work, social determinants of health work, there's opportunities to say if we had some upfront funding to seed a program, then if we had some type of a global or bundled payment that was necessarily divorced from actual codes, we may be able to create some margin there that we can reinvest on an ongoing basis on some of these non-billable services. Now thankfully, we're starting to realize that like peer recovery and support is a very important and a reimbursable service, but that's not always the case. So if you get some type of a global or value-based payment that is loosely tied to helping someone on the recovery journey, then you can potentially use some of that money to invest in some of those services that aren't necessarily, quote, billable. So the idea maybe would be that the kind of the big tent that would put out there is there a way for us if the federal government and state governments decided, look, this is really important for us, it's important for our state, it's important for our country. And thankfully, from the ID perspective, my vision is that the folks in Nashville are going to be able to help globally, if not at least nationally in times of concern. Could we create some up upfront payment mechanisms within kind of the structure that already exists in federal and state law that will allow us to do exactly that? Maybe we don't have to sit there and find E/M codes or other types of like DRGs, for example, like inpatient, but instead we can look at some type of a funded, focused approach to help not only battle infectious disease outbreaks, but also help prepare the system for future, then allow you the freedom as the thinkers to get paid to think and solve problems, even though they may not be a code necessarily to hit for it. I don't know. That's my starting point of this.

Buddy Creech: [00:18:45] I love this. I'd be curious what Nancy-Ann thinks, because from my standpoint, if we think the E/M codes are too low, if our reimbursement for the clinical activities that we do for an individual patient are too low, the strategy of just do more is really off putting because I can't do that much more. Our bandwidth as providers is as stretched as it ever has been. And so when I tell our junior faculty or others around the country, well, the solution is just do more consults, billing more time or with greater complexity, that's barely a rounding error maybe. And so, Nancy, does this resonate, this idea of creating thematic bundles that are either around social determinants of health or disease states or pandemic preparedness? I mean, where does that money come from?

Nancy-Ann: [00:19:36] It could come from, in the Affordable Care Act, we created a public health trust fund that was supposed to create almost like a mandatory, it wasn't mandatory, but a mandatory stream of funding like Medicare and Medicaid have. So it's that on that side of the budget, therefore not subject to sequesters. Well, actually, Medicare can be subject to sequester, but Medicaid hasn't been. Not subject to the annual appropriations food fights like the one we just sort of had the thing over the debt limit and we decided on what the budget caps are going to be. So not subject to that. And it was supposed to be 2 billion a year. I think something like that. I say was supposed to be because it started off being that and the way that the funding was spent was the secretary of HHS had the authority to propose how to spend it. At that point, it was Secretary Sebelius and she worked with then head of the Centers for Disease Control and Prevention, Dr. Tom Frieden. His team at CDC worked on this, and they came up with a series of grants. But it also went to sort of nationwide priorities, HIV being one of them, prevention activities. So, look, if we decide it's a priority, we can find the money. That money has routinely been borrowed or spent on other things in the past few years. It was supposed to be on top of whatever the baseline budget for public health was.

Buddy Creech: [00:21:03] Okay.

Nancy-Ann: [00:21:03] The two of them were supposed to be on top of that NIH and all that. And it's been ended up digging into the being used to bring the base up. That's just making the numbers work, if you will. For one brief shining moment, there was agreement amongst 60 Democrats and 218 in the House and the administration, let's put this money aside and I believe there could be bipartisan support for something like that in a future world where there's bipartisan support for anything in health care, which I hope that will not be too far away. I think there could be support for that. So you could get that money. My problem is how do we then get it down to the level of sort of what I said before, like who's on the other side of the table. So a grant to whoever the chief public health officer is for the state of Tennessee who would maybe work with Gabe or his whoever is now the Medicaid director in Tennessee doing. Yes, I could see that. But how does it then get down to the doctor, the Buddy Creeches and the other infectious disease specialists?

Buddy Creech: [00:22:03] Yeah, that's where we've really struggled, is that many of the things we do have remarkable funding. For the last three years, many of us have been knee deep in bringing new vaccines to bear. And to be honest, the resources made available during that time were remarkable and they were necessary to get it done so quickly. But there was no shortage of resources we were able to hire. We were able to pay research nurses, what have you, that didn't change any of our salaries. That didn't change any of the yet recruiting techniques we have because we still have a residency and fellowship situation undergraduate medical education that pays far less than minimum wage it feels like during those times of training and then a compensation structure that despite trying to eke out as much as we can, still is not financially neutral with someone who doesn't choose advanced training. And so we've turned to things like telemedicine, we've turned to things like various consultancies or other side hustles to try to supplement that. And it feels strange, especially on the heels of a pandemic, when that value proposition societally seems high. I now feel like I'm a super complainer. [laughs] We have one of the best jobs on the planet. I feel stupid for even complaining about this because my gracious, it's so great. But that relative compensation with our colleagues is a challenge.

Nancy-Ann: [00:23:35] What you receive for seeing an individual patient. That's the rub. And I guess part of me wonders, is there a way to redefine side hustle? So I hear you. You're there to see an individual. You know, you were taught that medicine is one by one, but a lot of what infectious disease specialists do is not just one by one. It is broader based...

Buddy Creech: [00:23:58] Agreed.

Nancy-Ann: [00:23:59] ..about how we take care of people and how you prevent disease. So is there a way to make the funding of that piece of it be a more relevant part of an infectious disease specialist's income. For example, as you say, the money was there when we needed it for Operation Warp Speed and for vaccines, and hopefully it will continue. I hope this is a whole new renaissance and vaccine development. Seems like it's going to be.

Buddy Creech: [00:24:26] Agreed.

Nancy-Ann: [00:24:26] So do the pharmaceutical companies that are doing that work and the NIH and those that are doing that work, do they realize the value of infectious disease specialists? Would they be willing to kick in some of the funding for more residencies?

Buddy Creech: [00:24:40] This is a great word. So this is indeed. So one of the things that PIDS has been working with some of these industry partners is to fund summer research opportunities for undergraduates and early medical students, to give them just a sense of what it's like to be in infectious diseases. It's building a pipeline. Because at this stage, what I think a lot of us are worried about is this is no longer a bunch of us complaining about compensation. It's really hindering our diversity and equity and access initiatives because there are so many coming out of medical school with so much debt. The choices they have for specialty are now hindered by the quarter million or half million dollars in debt that they might have from undergraduate and medical training. And so if we want our workforce to look like those we serve, then we're going to have to be creative about things like loan repayment and maybe convincing our health care systems that my individual compensation should not be merely tied to the RVU-based revenue that I can generate, because that's not in our current structure ever going to be enough for the non-procedural specialists, especially for something like ID that sprinkles across all of the disciplines, right? We talked about oncology earlier. Infectious complications during cancer therapy are a leading cause of death of that patient population. I think our oncologists, maybe they'd be willing, to just chip in a little bit of their clinical revenue to support ID care and ID work, especially if we can provide that value proposition to them. And that's acting locally.

Nancy-Ann: [00:26:24] I don't know if it's still going on, but there was a value-based care demonstration out of the Medicare Innovation Center about cancer care. I don't know if it included the infectious disease complication component of it or not.

Buddy Creech: [00:26:37] Sure and undoubtedly it may have. And now the question is how do we leverage that locally to be able to do more? So one of the things I hinted at and Gabe, I'm going to be curious on your thoughts here about one of the things that we pivoted very quickly into during the pandemic, because we have the luxury as non-proceduralists to do it, is telemedicine and being able to provide digital care to a broad swath of individuals. And like I said, many of the things we do, that's completely sufficient. Do you see some market forces around telemedicine that either put that at risk or that make you think, boy, we've got to really keep investing in this, but do it really smartly?

Gabe Roberts: [00:27:17] Yeah, I mean, I tend to always be in the latter category of that. I don't know that I can always say that I [laughs] execute on smartly as well as I would like to. My thoughts are and talking to a bunch of directors, even frankly around the country still is that telemedicine has proven that it increases access and that it works. It may not be quite as I don't think unregulated or deregulated is the right phrase, but it may not be quite as easy, perhaps, to go in between in-person and telemedicine in the future as maybe it has been during the pandemic. But I think personally that we'd be doing ourselves a disservice if we tried regulatorily to pull it back too far. In a state like Tennessee, that outside the kind of major metropolitan areas is very rural, especially Appalachia region. It is really important to be able to connect with folks. Telemedicine has been proven to be valuable there. So I think at the high level, generally, you may see more requirements around, you got to have an in-person client relationship with the provider, client relationship, etcetera, before you can kind of go down and forward. But from my perspective on the ID side and again, I'm not a clinician and don't even try to play one, but it seems like from the from the professional consult piece, there was a lot of momentum on that even before COVID. I mean, the Project Echo pilots that were going on around trying to bring specialty from kind of the city to different parts of the state was pretty important. The ideas around trying to put some 24/7 telemedicine, critical access in rural hospitals for hospitalists or for other types of ICU type docs to be able to allow those hospitals to stand up and be an access point in critical situations for their community.

Gabe Roberts: [00:29:05] All of those things were gaining steam before COVID. So I would hope that from your perspective, the consult piece and the potential for additional reimbursement around that would continue. There always is a budget complication with Medicaid. The tradeoff is very real to directors and policymakers that if we spend money on this, that means they have less money to spend somewhere else. And so the complicating factor of being a director is that you have to choose three really good ideas, often out of ten really good ideas of what to fund. Doesn't mean the other seven aren't worthy. It just means that you had to make a really hard decision. And so, you know, that's always going to be something that would be out there that if I were in your position and in the members of your society position, I would be cognizant of. But I think that goes to our earlier conversations around being around the table, making sure you're educating the policymakers, making sure they understand the nuances of reimbursement and the difficulties, and that how even if we support some drawback or we're not opposed to some drawback around some element of telemedicine, make sure we keep this other critical lifeline open, because it might mean the difference literally, of life and death between somebody in a rural community not being able to access somebody at Vanderbilt, for example, on a consult basis as needed on a Saturday night or Sunday morning at 2:00 in the morning.

Buddy Creech: [00:30:20] That's a great word. I'm going to ask one final question of both of you. And this is really you have carte blanche on this. I think the pandemic has taught us a lot of things. It's taught us how to be flexible. It's taught us that we don't know what we don't know sometimes. I'm curious what each of you sees as maybe one of the more exciting developments in this sort of healthcare economics space or how we how we do this, how we take a limited financial resource that we might have and how do we apply that to making sure the people in our care, but more importantly, the people in the US are as healthy as we can be. Are there things that that you've got that are just that are just exciting for you? And Gabe, I might start with you and, and then go to Nancy-Ann on this one.

Gabe Roberts: [00:31:10] I appreciate that because 100% guarantee that whatever Nancy-Ann has is going to be more exciting than me. [laughs] So thank you for let me go first and clear that table.

Nancy-Ann: [00:31:17] [laughs] We'll see about that.

Gabe Roberts: [00:31:18] So there's two things that are on my mind. First of all, I love Medicaid, so I'll start there and I think from a perspective of Medicaid policy and how important Medicaid is to our society, it's an incredible program. It's got incredible interest. For a number of reasons, we have more people in the program now than we ever have before. And from a perspective of seeing private investor interest beyond kind of a Medicare Advantage or a commercial piece, a lot of folks are looking at Medicaid and trying to figure out what can we do there to bring innovations, increase health outcomes for folks that are on the program. Et cetera. Et cetera. So I think generally, that's one big bucket. One small subset of that bucket is the idea that when you have good Medicaid policy and that can include, by the way, things like we're talking about, like what is good for Tennessee, for example. Is it good for us to have a well-prepared and kind of well-stocked ID provider roster down the board? There's opportunities to tap into federal state funding, matching opportunities that might potentially take some small investment in multiply that by 2 or 3 and in some cases four, assuming that you can really make the case or the nexus for Medicaid and I would think that on the pediatric side, that case is probably relatively easy to make.

Gabe Roberts: [00:32:34] So I think that's interesting. And then the other thing that I'm totally not qualified to talk about, but yet it's the thing I find myself reading more about than anything else is kind of this advent of artificial intelligence and what we can do to leverage that, not to replace the providers, but how can we use that as a force multiplier for the providers and get them to be able to allocate their precious time and resource more appropriately, but not doing so at the cost of their reimbursement? Is there a way for us to be able to, with technology, leverage their output to your point earlier, not asking them to do more, which is going to just make the problems you outlined at the beginning of this podcast even worse over time, but is there a way for it to be a synergistic whole? Those are the two things that I think are pretty interesting.

Buddy Creech: [00:33:22] That's great. Nancy-Ann, you get the final word.

Nancy-Ann: [00:33:25] Like Gabe, I alternate between being frightened and terrified by AI, yet really, really excited about the potential that I see. And I did see a company not too long ago that is doing in pathology, using AI to be able to read tests in a more consistent fashion and not depend on just basically the human eye. And it does seem like that could be an innovation that would help speed the detection, proper detection and understanding and diagnosis of disease. I'm not a clinician, nor do I play one like Gabe, so you're the one, Dr. Creech, who should judge that, but to me, that seemed exciting. And then we've had a lot of discussion this, this afternoon about value-based care. You've got me thinking that there's a pony in there somewhere in the relationship between infectious disease specialist and oncologist and oncology and that team-based care, which I think everyone agrees that needs to be a team. And I do think there have been a few demonstration projects around. Can we provide a bundle payment and end up with patient centered care that is high quality, more efficient and to be frank, depends less on arguably improper incentives around the cost of drugs and who's going to be getting that margin? It seems to me that infectious disease specialists should be at that table. Among many. But at that table, as part of that discussion, when you mention, Buddy, the notion that it's important to call infectious disease specialists early, it's struck me that in cancer, that would be really the case. I don't know if that happens or not. It builds the case to be having that person on your team early.

Buddy Creech: [00:35:21] That's exactly right. And, you know, I think well, maybe I'll end with this is just to say that over the last few years, again, through IDSA, through PIDS and many others, there's been this real commitment to saying, you know, one of the reasons I went into infectious diseases is if I were a cardiologist, I'd have to really focus on the heart. With ID, we are these just centipede legs everywhere into all of the specialties, whether you're a surgeon taking out an appendix, well, you might need us for the post-op complication. If you're a neurosurgeon and the patient has an allergy to a particular antibiotic, you need us. We're highly integrated into all of the specialties within the academic medical centers or the private medical centers or the clinics that we may find ourselves. This really resonates with me, this idea that AI is going to be great, but I don't want to fill those unfilled positions in our fellowships with robots because that gets really scary to me and I have some Arnold Schwarzenegger Terminator things start going through my head really fast. But at the same time, if we can improve our bandwidth, if we can be there from the outset, maybe in the context of these team-based reimbursement models. If we can try to figure out how to think about things locally with our state Medicaids and then engage with those federal match dollars for things like pandemic preparedness or telemedicine infrastructure. And if we can continue through a real grassroots effort, but also at the highest level of engaging with policy makers and key opinion leaders and all of those drivers of health care finance reform, if we can continue to do that, then any compensation changes that happen, happen based on value, not because we're putting them on the backs of our patients by trying to eke out a better E/M code from that individual.

Nancy-Ann: [00:37:17] Right. Or to do more of something higher volume of something, which is also not good.

Buddy Creech: [00:37:23] That's exactly right. Well, at the end of the day, I will say we have the best job in the world. It is fulfilling, it is rewarding, It is everything we always wanted it to be. And we look forward to a day where that can be maybe more right sized in its value. I have to tell you, both Nancy-Ann and Gabe, thank you for being incredibly gracious and kind with your time. I would love to take you both out to a really nice steak dinner. But apropos of our conversation, it might need to be a Wendy's or a McDonald's run, but that'll be fine. I will supersize the meal because that's just the kind of guy I am. Thank you all for joining me. This has been wonderful. We appreciate all the work that IDSA and PIDS is doing to really advocate for physicians and providers and all of those who call IDSA and PIDS home. You can find out more about what the society is doing at our websites so that you can see all of the ways in which we're trying to improve this really important aspect of pediatric ID and adult ID. Thanks for joining. This is Buddy Creech, and we'll see you next time on Let's Talk ID.