We work hard for the money pt.2: how IDSA is addressing ID compensation

Buddy Creech: [00:00:11] Hi, everybody. I'm Buddy Creech and this is Let's Talk ID. For years, PIDS and IDSA have been working together to improve the ID workforce and secure more appropriate financial reimbursement for the work that we do. In the first episode of this two-part series, I talked with Nancy-Ann DeParle and Gabe Roberts. They provided historical context for physician reimbursement, some of the challenges that we face as health care costs increase and some of the ways telemedicine may impact health care finances. In this episode, we're going to focus a bit more on what IDSA has been doing over the last three decades to address these fundamental issues in infectious diseases. Today, I'm joined by Dr. Dan McQuillen, who is senior physician in the division of infectious diseases at Beth Israel Lahey Health and assistant professor of medicine at Tufts. He's past president of IDSA and has been an active member of the society for over two decades, intentionally focusing on promoting the value of the specialist and increasing ID physician compensation. Dan, thanks for joining me today and I really want to jump right into this and see if you could walk us through the ways IDSA has been involved in this space over the last several decades. I mean, you've certainly been as close to it as anyone has been.

Daniel McQuillen: [00:01:25] Thanks, Buddy. I'm really happy to join you as well. What I'll do first is give some historical context, as you mentioned. As you'll hear later, the current way that Medicare or CMS reimburses clinicians for their work is through what's called the resource based relative value system. And that was developed in 1992. And if you remember back in the 80s, at least that's when I was in medical school, we were having these classes about HMOs and capitated care, and it was kind of a free for all as physicians could bill for usual and customary fees. There really wasn't a heck of a lot of regulation going on. In 1985, Congress passed the Omnibus Reconciliation Act that established a payment commission that would advise them on physician payment, and it also mandated a relative value scale based on site of service, skill and training, time and risk. CMS commissioned a guy named Bill Hsiao, PhD doctor at Harvard School of Public Health, a contract to develop an RBRV that subsequently was accepted and used by pretty much all of the US payers as their basis of payment for physicians. There's a couple of papers that were in the New England Journal in, I think, September 1988, and the basic formula that they created is kind of like E equals MC squared for physics.

Buddy Creech: [00:02:49] And hopefully just as complicated, right? You make it sound easy.

Daniel McQuillen: [00:02:53] Well, yeah, but it's not as effective. And so the resource based relative value was a combination of two, which is the work input by the physician RPC, which is the index of relative specialty practice costs and AST, which was the index of the amortized value of the opportunity cost of specialty training. The Omnibus Budget Reconciliation Act in 1989 switched CMS to this and in 1991, CMS delegated maintenance of this to a thing called the AMA Specialty Society Relative Value Scale Update Committee. It's a lot easier to say RUC than that. The AMA offered to establish this voluntary committee and the PRC, which was kind of a precursor to CMS, but is now a subset, accepted that. And so in January 1992 they started to implement this for physician payment. And not surprisingly, all the non-Medicare private insurers mirror the values that are established. But the really important thing is that Hsiao ran out of funding and they couldn't figure out how to basically value expertise and training. And so they dropped it from the equation. So this is you could stop here and say this is the basic problem for cognitive services.

Buddy Creech: [00:04:17] Well, that's what I was going to say, is because so much of the frustration comes in with the fact that even though we go through so much more training, even though we have such a high level of skilled expertise, it doesn't seem as if that's particularly valued over our general medicine or general pediatric colleagues. It's not treated any differently than anyone else. That feels weird to me.

Daniel McQuillen: [00:04:42] Yeah, I guess a way to look at it is there's probably personal levels of intensity. It's, for instance, very easy for me to take care of a septic shock patient and much easier than a surgeon has in terms of solving that problem an getting the patient through it. What the current system devalues is experience and judgment, both from training and time being a physician. Is a complex cognitive service less valuable because I've seen it hundreds of times and I can do it more efficiently? I don't think so. In fairness, the same can be said for a surgeon who has done a procedure 100 times and gets faster. I'm not sure that being able to provide a service or do a procedure more quickly decreases the value to the patient, and that's where the system falls down completely. There it is right in a nutshell.

Buddy Creech: [00:05:29] This is challenging. Well, I think that helps me understand some of the historical elements of this, is that how does CMS value the things that we know are valuable? How do we monetize that or how do we formalize that? I don't mean monetize it, I guess. I mean, how do we put that into a formula like E equals MC squared, like you said?

Daniel McQuillen: [00:05:46] Yeah, it's a very tough challenge. But I think sort of in context to this and what will kind of reflect how we got involved in this is it's really important to note that IDSA was growing extensively at that time. There's actually a really nice paper by Joe DelVecchio, one of our past presidents, that was in CID in 2005, and it talks about four decades of IDSA growing from infancy to adulthood. And there's the first table in there shows how many members there were by year. You know, in 64, there were 150. 1984 it was 1850 and 94 it was about 4500. There wasn't a critical mass to really do much at that point until the mid-1990s. The membership of clinicians who weren't in academic ID practice and IDSA staff were really both small and IDSA staff were really devoted to programs and member services, and they contracted their advocacy programs, which would be things with appropriations from NIAID, fraud and abuse issues, reimbursement and payment to a Washington attorney who was a health-related issues specialist named Steve Lawton. And Steve relied really heavily on IDSA members for expertise and input. At about the same time, late 80s, early 90s, IDSA formed a clinical affairs committee which was almost entirely nonacademic clinical practitioners. They began to focus on payment issues. The first thing they put a lot of effort into was home antibiotic infusion. That was led by a guy named Alan Tice and then other members of the committee, Russ Petrak and Larry Martinelli, in a task force on outpatient antimicrobial therapy.

Daniel McQuillen: [00:07:30] And so they came up with guidelines and standards at about the same time. Tom Slama, who's another past IDSA president, met in 1993 at Steve Lawton's request because of this PPRC forming and the RBRVS. So Tom gave a day up from his practice in Indiana and flew to DC to meet with someone named Roz Lasker, Dr. Roz Lasker, and she was an endocrinologist. And, if you look at her biography, she went into this because she didn't think she was getting paid fairly for what she did in the office.

Buddy Creech: [00:08:04] Wow.

Daniel McQuillen: [00:08:05] So she became a policy analyst for the PRC from about 87 to 93. So Dr. Tice had written a draft paper position paper on intensity and value of common ID services. Tom Slama flew in, spent about two hours revising that, met with Dr. Lasker, talked with her in a substantive way, and as far as they could tell, successfully convinced her of the value of ID services. And that gave input to the initial formative process. In 2004, Mark Leisure, the CEO, contacted Larry Martinelli, who at that point was involved in the CAC and had been heavily involved in OPAC guidelines to join the early AMA CPT editorial panel and then the RUC as a specialty society advisor. And he basically did the RUC part until about 2020 when I replaced him solely, although I started in about 2006 in that process, he was going to the CPT, which there are basically 2-to-3-day meetings. Each one meets three times in a year. So he was doing six of those in addition to being a solo practitioner.

Buddy Creech: [00:09:16] Wow.

Daniel McQuillen: [00:09:16] In Texas. But he kind of loves this stuff. [laughs] So it wasn't really it was like a hobby. Both of us, Larry and I have been RUC panel members. He twice me once during that process, Steve Schmidt did the CPT role until 2008. And then Ron Devine, who's in practice in Atlanta, started about five years ago and we started out with not much support and have gotten more support and more expert support over the years. Now, Larry probably had the most Martinelli That is the most influence on this in that when he dove in, he was part of a group of specialty societies who developed the outpatient infusion codes. So they brought them all the way through the CPT process and then presented them to the RUC panel to get them valued. And Larry was one of the driving forces of that. So the reason that our members can provide outpatient infusion and get paid for those services is directly a result of our involvement in RUC. He was also an integral member of the specialty society advisors who presented the E&M codes, I think the outpatient ones only, in the first five-year review process.

Buddy Creech: [00:10:28] You know, I think for many of our listeners, this is really complicated and at least for me, it's hard to keep track of all of the efforts that have been done. I will say you referenced Joe's paper. As a pediatrician, I love it when our adult ID colleagues use phrases like from infancy to adulthood. That makes me feel like we're getting our message out there. And so it's really good. If you haven't read that paper, it's an important one to look at because it gives us, it at least gives me a lot of respect and a lot of excitement over what the last 40 years have looked like in the world of infectious diseases. So, all right. At the risk of going a little bit deeper into this, because you almost lost me at E equals MC squared. And then there were some other things going on and some weighting and all of that. But like, I need to understand this RUC process a little bit more. I need to understand why this is complex. You've mentioned a little bit of it being this sort of zero-sum game. I can't imagine having to walk into a room where I've got to convince a neurosurgeon to devalue his or her efforts in order for mine to go up. That feels like a lost cause right out of the gate. But it's not that easy. But can you talk about why that RUC process is so complex? Why is it difficult to get headway there? What are we doing there

Daniel McQuillen: [00:11:44] Yeah, as you correctly identified, there are a lot of different factors. I think in terms of E&M codes, The big one is the one we already talked about is that the opportunity cost of specialty training is just out. And the current version of this is that a total RVU is a work RVU which is composed of physician things, time and intensity, technical skill and physical effort, mental effort and judgment, psychological stress. And then there's practice expense. So you've got to pay to keep the lights on. You got to pay for your nurse, your receptionist, your robot surgical machine, that sort of thing. And malpractice expense. Over the years, the practice expense amount of the one RVU has gone from well, less than 50% to well over 50%, where the majority of an RVU is actually practice expense. At this point, at least 25% of physician work done by cognitive physicians isn't accounted for by our RBRVS codes. A lot has been made about the composition of the RUC. There's 31 members in all, but if you take the chair and the representative from CPT and people out there, there's basically 25 specialty society members. Some are permanent. So IDSA gets a seat if we have one as one of the rotating seats that the American College of Physicians has, that goes to a specialist of some sort. In my time doing it, I was actually on the panel when the outpatient E&M codes got up valued 4 or 5 years ago, and the discussion around that was pretty good.

Daniel McQuillen: [00:13:23] The problem is that many years ago they decided to go to these things called global codes for surgical procedures. So you have a zero day global, which means all the code is paying for is the surgery and the effort on that day. Or you have a ten-day global and then there's a 30-day global. I think there might be a 90. I forget. Yeah, 1090, not 30. That encompasses all the follow up work. So if the surgeon does a procedure and then it's a 90 day global, they don't get paid anything else other than the global payment that encompasses them seeing the patient the day after surgery, discharge day, and then sometimes up to 3 or 4, depending on what the follow up needs are. There was this anecdotal feeling that those follow up codes weren't really being done and certainly not at the level that I would be doing if I came in and saw a patient for the same code. CMS and I think 95 proposed to eliminate global periods and go back to individual billing. Somehow Congress included something in Macra that blocked that. I'm not sure how that happened, but maybe you could imagine. And CMS ordered a study as a result of Congress requesting one that the Rand Corporation did, and they found that the ratio of observed to expected post-operative visits was 0.04 for ten-day global periods and 0.39 for 90 day global periods, which documented they weren't actually happening.

Buddy Creech: [00:14:54] Wait, but when you talk about those ratios, that would mean very few ten days are happening?

Daniel McQuillen: [00:15:00] Right.

Buddy Creech: [00:15:00] And honestly, very few 90 days are happening. So I want to make sure I understand this because this is one of our big challenges, is that I can only address compensation issues by volume to a certain point. Yeah sure, as a division we have said and our hospital don't give away free care. Yeah, you've got to bill for it. That means you need to see every patient every day. And I have to admit, Dan, like I worry a little bit about this and we talk with our trainees about it a bit. I never want our families to bear on their shoulders the compensation needed for me to have fair compensation for the work that I provide, right? And so we kind of have this model that if I'm not making a contribution to the care that day, if it's just a social visit, that feels really weird to bill the family for that, right? But we don't have a similar type of this is what it costs to take care of Hematogenous osteo. This is what it takes to care for bacterial meningitis. We are fully dependent on those daily codes in the hospital or those outpatient visits in follow up, whereas I might not see a surgeon for like two days because they're not having to do those same type of follow ups. Do I have that right?

Daniel McQuillen: [00:16:13] Yes. You do.

Buddy Creech: [00:16:15] Well, that's goofy.

Daniel McQuillen: [00:16:17] I don't want to say that every surgeon doesn't see their patients. That's not true.

Buddy Creech: [00:16:20] For sure. For sure.

Daniel McQuillen: [00:16:21] But I think a lot of the visits are exactly as you described. You're dropping in. You're saying hi to the patient and you're out. Sure, that's an assessment. You know, the patient doesn't look like they're in septic shock or whatever, but it's not what the proxy is. The proxy is for an E&M that involves a whole set of things that get done that has a prescribed time for those, each one does, and so you're not really doing that.

Buddy Creech: [00:16:46] But, you know, Dan, I could see, though, the interest here for me is that if we were to pull all of our colleagues, I would suggest that one of the things that they loathe the most would be documentation. That would be my guess. After we switched over to Epic, I can guarantee you that's one of my headaches. What's interesting about it is that our surgeons need to...I'm going to make a comment that I think is true. I need you to fact check me here. If a surgeon does an appendicitis, that goes well and she or he is looking after that patient over the next few days, if they don't leave a note, they're not losing money. If they do leave a note, that's better. It's just better practice. It's covering themselves from a malpractice standpoint, There are plenty of benefits to dropping a note. But whether they do it or they don't, it doesn't seem like they're losing money. For us, that's just very different.

Daniel McQuillen: [00:17:39] Right.

Buddy Creech: [00:17:40] Okay. Just making sure I've got it. Because my gracious.

Daniel McQuillen: [00:17:44] One idea that's come up through the cognitive specialty coalitions that we're a part of is this idea of a technical expert panel. And we're actually advocating for that in our comments to the proposed rule that came out. It wouldn't be in place of the RUC process because that process is pretty well set up to do what it does, which is primarily valuing procedural codes. Now, you can argue that the data inputs aren't necessarily great because when you go back to the things that go into the physician work, in terms of technical skill, physical effort, mental effort, psychological stress, the surveys that go out for a code get sent to the people that use them. But the subset of people that get those surveys are specialist society members.

Buddy Creech: [00:18:35] So this should be...Oh, I got it.

Daniel McQuillen: [00:18:36] And so part of the survey is how much time does it take you to do this? How intense is this? Is it more or less intense than the reference codes? What other reference codes would you suggest? Things like that. And the, like all surveys, not very many people answer them. And so sometimes the numbers are quite small. And so this expert panel idea is to kind of remove everything from that and try to figure out a way to properly value cognitive effort. And at the same time, you have to be able to measure it. And that's a really tough thing to do. There are some databases from, say, airlines and a couple of other industries that do this, that potentially could be applied to that sort of thing. But it's seen as a big threat proposing something like this, because it's you know, you're going to sort of take this away from the AMA RUC process. And our thought is to develop something in parallel to value it right.

Buddy Creech: [00:19:33] Yeah. And to supplement rather than to replace. Well, I'll tell you this, Dan, if the work RVU takes into account physical effort and psychological stress, I am more than happy to do pushups while I try to figure out which antibiotic regimen is going to make my ASP team less angry with me. And as I anxiously wring my hands to make sure that I pick vancomycin only when I should. So I am happy to factor that in. You know, I want to ask you, you've hinted at this a lot, but maybe we can just summarize it very briefly. What are we currently doing? And if you'll speak to IDSA, I may put in a few things that that PIDs is currently. Be doing, but what are our current efforts focused on and what do we need to know about?

Daniel McQuillen: [00:20:14] We're obviously continuing to have representation at CPT and RUC because I think you can't not have someone there to be helpful in influencing the process. We do most of our efforts in conjunction with other cognitive specialties. Just because you get a bigger critical mass on things, a lot of it is focused much more so than it was even eight, ten years ago on Capitol Hill, at the White House, at HHS, at MedPAC. I've been in all those places and talking with those people. The good things the pandemic did is it elevated our position even higher than it was before in that we're really looked at. We get calls from the White House and some of these other places, to help out with them, developing what their policies should be on things like that. We're working on advocacy things. You've probably heard of the bio preparedness workforce pilot.

Buddy Creech: [00:21:06] Right, right.

Daniel McQuillen: [00:21:06] It's a result of our advocacy that it got included in the Prevent Pandemics Act. So it was basically established as a pilot program, but not funded. The Public Health Loan Repayment program was authorized for 100 million annually. We were asking for 50. We're still trying to advance that through Congress and get it funded, which you can imagine is a difficult prospect in this current Congress.

Buddy Creech: [00:21:33] Of course.

Daniel McQuillen: [00:21:34] Although we actually have bipartisan leaders who are chairs or vice chairs of the committees that handle this sort of thing. So I think it has a decent prospect. We're advocating on Capitol Hill to get the E&M coding fixed. What basically happened, the great thing was the documentation that you were talking about is now not required either inpatient or outpatient. The outpatient codes went up. We stayed about flat. We as in ID, because of the budget neutrality thing. Last year, some of the inpatient codes went up a tiny bit. Most stayed stable and two of them dropped significantly. Now this is the same high level, high intensity, complex problem inpatient, who's really sick, who suddenly is worth 20% less for no real reason.

Buddy Creech: [00:22:24] Yeah, it's a zero-sum game.

Daniel McQuillen: [00:22:26] We're advocating for Congress to tell CMS to fix it. The other thing that we're doing is we're advancing a couple of proposals. One that we are already working on, which would be an outbreak activation code. So if the next COVID pandemic comes by and we again get forced into basically managing that, we would qualify for this extra bump in our payment. Another one that we are in the midst of formulating, we don't have specific representatives or senators to introduce it yet, but we're in talks with a number of them would be an incentive bonus payment modeled on what was given to primary care for five years and general surgery for five years when they were having trouble. Where you would get a 10% bonus on your Medicare billing for five years.

Buddy Creech: [00:23:15] Yeah, yeah.

Daniel McQuillen: [00:23:16] That's another way of getting more money put into the system without having to account for some offset and dropping payment as you would in the fee schedule.

Buddy Creech: [00:23:27] Yeah, I think that's really helpful. On the PIDS side of things, we're relying on IDSA a lot. We're contributing through those mechanisms and several of our members have been engaged in that process, which is, which is really helpful, right? Because for some of our leaders, hearing about the pediatric experience can be a little bit more compelling than for the 90-year-old or the 80 year old that we might be caring for. And that's just how it is. But, you know, one of the things that we've done a poor job of on the pediatric side is really counting or accounting for all the different things that we do. And there's even a real big variability in what a clinical percent effort really is. So what a CFTC might be at Vanderbilt might be very different than what a full time equivalent from a clinical standpoint might be at any number of other institutions. So we've got a special task force that's really trying to focus in on that because if we can start there, that at least starts to level the playing field so that when we then get some of our compensation data, not the aggregate data that we get through the AAMC or for us, the AAAP, but when we can get real compensation data that's Pedes specific, similar to what IDSA has done for its membership, then we can start to say, okay, we can benchmark now and we can say you're at the 30th percentile, 50th percentile. At the end of the day, our medicine chairs, our hospital administrators, our pediatric department chairs, I think they're going to have to respond to data.

Buddy Creech: [00:25:00] And as you said before, when we don't have great data or when that data, those data are just really unclear. It's really easy to dismiss them. And so I really want us to be able to provide good data. So maybe this is a plea for us to say when IDSA or PIDS sends out a survey about compensation, for the love of Pete, or maybe just for the love of Dan and Buddy, please fill out that survey because the more data we have, the better it will be and the more compelling it will be. All right. So in addition to filling out surveys, what else can our members do? What can we do to be engaged.

Daniel McQuillen: [00:25:37] That ties in really well to the physician compensation survey or initiative that we're doing. And you can actually find there's a page on physician compensation on the IDSA website. There is a survey out now that was pretty well targeted at different areas that we didn't have tons of data on. We've been doing these about every two years. The goal at the moment is not to get a big, huge survey that has a lot of data of what the bottom line is. It's exactly what you were talking about. We've discovered not that this is really news, but an ID FTE is different depending on what you do.

Buddy Creech: [00:26:12] Absolutely.

Daniel McQuillen: [00:26:13] And so you need data on on how that's accounted for. And then the other thing that's become very clear in any setting is that if you have some incentive component of your salary, you actually do better in terms of payment. And we're also trying to get towards with focused interviews, what are the outside things you do that aren't direct patient care that you get compensated for? How do you get compensated for? How does that work? To try to get examples that people could then take to their local venue, whatever it is. And this is definitely going to be different from an academic setting to others. We're actually about to start focusing on people in academics to try and bootstrap that.

Buddy Creech: [00:26:57] Sure.

Daniel McQuillen: [00:26:57] So I'd say just like you did, if you get a survey, take some time and answer it, it's going to be really helpful. The other thing that's happening is there are free one-hour, one-on-one compensation meetings for IDSA members. They're all with some people from our consulting group, ECG, and they'll go through your contract, how you're being paid, what the opportunities are, what you might do better. And I think it's hugely important. This is more towards actualizing these things with also efforts to bring this out across the country in smaller groups and do things like role playing about negotiations and that sort of thing. To be able to do this. I can tell you that Cesar Arias, who is the head of ID down at Houston Methodist, basically took the information from our two playbooks that we've developed. One is a value-based contracting, the other is just negotiation and took it to his department of medicine and basically got all of his faculty members salaries raised based on that kind of data. An essential thing to do that we don't do enough is I should be taking our chief of transplant surgery with me to argue for getting increased reimbursement

Buddy Creech: [00:28:14] Totally agree.

Daniel McQuillen: [00:28:14] The fact that they can keep their program going because I'm involved.

Buddy Creech: [00:28:17] Absolutely. Absolutely. And that's where I feel like we can start to make some inroads, because if we've learned nothing over the last few years, ID is kind of important.

Daniel McQuillen: [00:28:28] Yeah.

Buddy Creech: [00:28:28] And whether it's on the discovery side, the policy side, everything in between, we're kind of critical. And I think a lot of our colleagues can say the same. I'm not trying to single us out, but I am saying this is a particularly prime time for us as ID specialists to begin to make several arguments that we're necessary for the health care system. We're incredibly valuable at a baseline. And then there are these punctuated marks where we're absolutely essential. I think we're also starting to get to the point where it's becoming an equity and access issue. You know, I mentioned in the first episode of this that to make the decision for a pediatric resident to go into ID to make that a financially neutral decision, you have to get a $1.5 million check as you enter ID fellowship in order to make that make sense. Okay. Nobody gave me a $1.5 million check. When I started fellowship. I looked for it. They told me it was in the mail. It's not there. We can get there with things that IDSA and PIDS have been working on, like loan repayment or other things. But as our students come out of medical school with hundreds of thousands of dollars of debt, as many of them care for large families, extended families, or may have other requirements and needs, we've really got to make sure that it's not financially disincentivizing to do this really important work.

Buddy Creech: [00:29:55] I'll be honest with you, Dan, I don't know how you do all the stuff that you're doing. You know, you're doing all this stuff. You're leading solid organ transplant ID. I like I don't understand the time commitment that this must be. So I'm going to say thank you for doing that. Thank you for advocating. I'm going to feel guilty every time I get a survey with your name on it and I don't fill it out because that just seems goofy at this point. There's a lot we can be doing. We're able to do that because of the work you and many, many others are doing. And maybe this is a call to arms for us as members of IDSA and PIDS and all of our partner organizations. Let's do all we can, not only for ourselves, but really for a future generation and generations to come of ID providers. We want not only a full starting five on the team, but we need a good bench of folks that are learning how to do this and taking advantage of this wonderful work we get to do. Dan, thank you for taking your time like this. This has been amazing for me to hear some of the history of this and I can't thank you enough for it.

Daniel McQuillen: [00:30:56] And thanks I've enjoyed it a lot. I like doing this and I'm very passionate about my specialty. The more of our members we can get involved in this process, the better. So if you do anything from this podcast that it's to go to the member advocacy program and put your information in there and volunteer. There are plenty of opportunities to see your congressperson or your senator, either in Washington or locally. Nothing gets their attention better than a constituent and you can tell them what it's like on the ground and what it's doing for their other constituents. That really resonates. And that's part of the way we've been able to make some of the progress we've made over the past couple of years. In addition to IDSA actually investing in a second lobbying firm that has more access to the other party, we're meeting with members instead of staff now, which is both a treat and really helpful.

Buddy Creech: [00:31:50] That's a great word. And I'll tell you right now, my inbox rule is that if I get an email from Amanda Jezek, it goes to the top with a big red flag. Not going to say no to Amanda, almost no matter what she's asking. Now that comes at my and maybe IDSA' own peril, but if you get an email from IDsociety.org, just do what it says and we'll be in good shape. [laughs] Dan, thank you for the time today. We appreciate it and hopefully we'll get to see each other soon in Boston and maybe on a future podcast. Thanks so much.

Daniel McQuillen: [00:32:20] Sounds great. Thanks, Buddy.