Where Is the ID in COVID-19?
Rochelle P. Walensky, Daniel P. McQuillen, Sara Shahbazi, John D. Goodson
Abstract
Letters3 June 2020Where Is the ID in COVID-19?FREERochelle P. Walensky, MD, MPH, Daniel P. McQuillen, MD, Sara Shahbazi, PhD, and John D. Goodson, MDRochelle P. Walensky, MD, MPHMassachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (R.P.W., J.D.G.), Daniel P. McQuillen, MDBeth Israel Lahey Health–Lahey Hospital and Medical Center and Tufts University School of Medicine, Burlington, Massachusetts (D.P.M.), Sara Shahbazi, PhDMassachusetts General Hospital, Boston, Massachusetts (S.S.), and John D. Goodson, MDMassachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (R.P.W., J.D.G.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-2684 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: The coronavirus disease 2019 (COVID-19) pandemic has challenged all of medicine. However, in recent weeks, the nation's need for more infectious disease (ID) expertise has become a clear focal point. As the virus swept across the country, distress over constraints—tests, swabs, personal protective equipment, and ventilators—dominated the discussion. There is more to the story. Following a decade-long trend, in 2019 to 2020, ID programs nationwide saw just 0.8 applicant for every open position; 38% of ID programs failed to fill training slots, and 19% could not fill any slots at all (1). Simply put, cognitive specialties, such as ID, have attracted fewer physicians to the field than other, high-income–generating specialties (2).Objective: To examine how the distribution of ID specialists matches the needs of the COVID-19 pandemic across the United States.Methods: We determined county-level ID physician densities—the number of ID physicians per 100 000 persons—by using 2017 Medicare Provider Utilization and Payment Data (3). We calculated the U.S. national average of ID physician density, assigning each county to 1 of 3 categories: ID physician density above the national average, ID physician density below the national average, and no ID physicians.We then used USAFacts to aggregate data from the Centers for Disease Control and Prevention and public health agencies (4). Using the Geographic Information System tool, we plotted county-level COVID-19 confirmed case rates per 100 000 population (12 May 2020). Because of the skewed distribution of cases nationally, we divided counties into quartiles.Findings: In 2017, the national average density was 1.76 ID physicians per 100 000 persons; the distribution is geographically skewed (Figure 1). Of the 3142 U.S. counties, 331 (10.5%) and 312 (9.9%) have above- and below-average ID physician densities, respectively; 2499 counties (79.5%) do not have a single ID physician. Therefore, 208 million citizens live in counties with no or below-average ID physician coverage.Figure 1. County-level ID physician density for the United States.The average ID physician density in the United States is 1.76 per 100 000 persons. Counties with ID physicians above this national average density are shown in blue, those with below national average density are shown in red, and those with no ID physicians are shown in white. ID = infectious disease. Download figure Download PowerPoint Among the 785 counties with the highest quartile of COVID-19 disease burden (Figure 2), 147 (18.7%) and 117 (14.9%) have above- and below-average ID physician densities, respectively; 521 (66.4%) have no ID physician coverage. In the second highest quartile of counties, 88 (11.2%) and 110 (14.0%) have above- and below-average ID physician densities; 588 (74.8%) have no ID physicians. Among counties with the lowest COVID-19 burden, approximately 95% do not have a single ID physician.Figure 2. Confirmed COVID-19 cases reported per 100 000 population, by county, 12 May 2020.COVID-19 = coronavirus disease 2019. Download figure Download PowerPoint Discussion: The distribution of ID physicians in the United States is geographically skewed. In the counties with the top quartile of COVID-19 cases today, 80% have below-average ID physician density or no ID physicians at all. Furthermore, nearly two thirds of all Americans live in the 90% of counties with below-average or no ID physician access, and these counties encompass vast—largely rural—parts of the country.Data demonstrating the association between ID physician care and COVID-19 clinical outcomes have yet to emerge. However, for many other infectious diseases, a robust evidence base supports the association between ID physician intervention and improved outcomes, including lower mortality, shorter length of stay, fewer readmissions, and lower total health care spending (5). The current analysis did not account for other professions capable of delivering public health or ID-specific care (such as epidemiologists, advanced practice providers, pharmacists, and infection preventionists) or shortages in other cognitive specialties collaborating with ID physicians to manage patients with COVID-19. Although limited literature informs the “right” number of ID physicians in a population, our current distribution during pandemic times is probably far too sparse.The deficits in our ID physician workforce today have left us poorly prepared for the unprecedented demand ahead. Telehealth stretches the reach of constrained ID expertise, extending clinical and public health management into underserved rural areas, but can succeed only if the Centers for Medicare & Medicaid Services and other payers fully embrace this tool.While urban centers move toward the identification, containment, and treatment strategies required in the absence of herd immunity or an effective vaccine, rural counties offer fertile ground for the spread of severe acute respiratory syndrome coronavirus 2. Faced with a surge of patients with COVID-19, these rural counties will be left wanting for the public health and clinical care activities ID physicians provide. The current experience with an overextended ID workforce is a cautionary tale. Our nation's health and future clearly depend on a long-term strategic ID workforce plan.References1. The National Resident Matching Program. Match results statistics: 2019 MSMP match results report. Accessed at www.nrmp.org/fellowships/medical-specialties-matching-program on 29 April 2020. Google Scholar2. Walensky RP, Del Rio C, Armstrong WS. Charting the future of infectious disease: anticipating and addressing the supply and demand mismatch. Clin Infect Dis. 2017;64:1299-1301. [PMID: 28387806] doi:10.1093/cid/cix173 CrossrefMedlineGoogle Scholar3. U.S. Census Bureau. County population totals: 2010-2019. Accessed at www.census.gov/data/tables/time-series/demo/popest/2010s-counties-total.html#par_textimage on 29 April 2020. Google Scholar4. USAFacts. Coronavirus locations: COVID-19 map by county and state. Accessed at https://usafacts.org/visualizations/coronavirus-covid-19-spread-map on 29 April 2020. Google Scholar5. Schmitt S, MacIntyre AT, Bleasdale SC, et al. Early infectious diseases specialty intervention is associated with shorter hospital stays and lower readmission rates: a retrospective cohort study. Clin Infect Dis. 2019;68:239-246. [PMID: 29901775] doi:10.1093/cid/ciy494 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Gilbert A HandalTexas Tech University5 June 2020 Infectious Disease specialists The lack of ID specialist is just about appropriate compensation. Even we have three more years of training (six years total including residency) we are the lowest paid physicians regardless of the exposure to many infectious diseases and the risks associated with caring for some of the sickest patients. Our consults do not usually do not have procedures and the payers don't care about knowledge , expertise, years of training and continuous updates but get away paying ID specialists as if they were PCP with no further training. I also believe the AMA with its corrupt system of RVU has not given knowledge base specialties their worth and provides only lip service while they continue their arrangements for income with HHS Keep on doing this and you will see , as the new graduate look more carefully at the return for their years of investment you will see a shortfall of every one of the non procedure sub sub-specialties. Stephen GreenSheffield Hallam University, Sheffield, UK18 June 2020 The United Kingdom is also short of Infectious Diseases Physicians It is not only the USA that is experiencing a lack of Infectious Diseases (ID) physicians. The United Kingdom (UK) was for many years disinclined to train ID physicians and to appoint them to consultant-level posts.(1) This was despite the existence of a government-funded National Health Service (NHS) with salaried doctors. Even though the situation has at times improved somewhat over more recent years, and despite the advent of dangerous infections like hepatitis C, HIV, MDR-TB, and a multiplicity of antimicrobial resistant microbes, there are still hospitals in many of the UK's major cities and towns that do not have a doctor on staff with expert training in ID. Now, as if to emphasize how chronically poorly prepared the country had remained, the UK sadly finds itself with one of the most pressing covid-19 problems in the world with, at the time of writing, well over 40,000 proven fatalities in a population of 68 million - indeed it is only beaten on overall numbers of covid 19-related deaths by the much more populous USA and Brazil.(2) We absolutely must all - from the top downwards - learn lessons from this, and ensure that in the future the specialty of ID is enabled to grow. For example, a healthy infection-related research program, for example for vaccine development, depends on it. After all, the next zoonotic pandemic after covid-19 may be even worse!(3) References (1) https://www.bmj.com/content/368/bmj.m953/rr (2) https://www.worldometers.info/coronavirus/ (3) https://doi.org/10.1016/j.jinf.2020.05.015 Rochelle P. Walensky, Daniel P. McQuillen, Sara Shahbazi, John D. GoodsonMassachusetts General Hospital, Harvard Medical School, Beth Israel Lahey Health-Lahey Hospital, Tufts University School of Medicine30 June 2020 Authors' Response to "The United Kingdom is also short of Infectious Diseases Physicians" In response to our paper, Where is the ID in COVID-19, Dr. Green remarks the US is not alone in neglect of public health infrastructure, defined pandemic response plans and longitudinal support of its Infectious Disease (ID) workforce. ID physicians meaningfully contribute to the COVID-19 response through development of infection control policies, diagnostic stewardship, and research and patient care, often leading multidisciplinary cognitive care teams. Recognizing that the surge of COVID-19 cases would overwhelm hospitals yet restrict access for non-COVID-19 patients, the Centers for Medicare & Medicaid Services (CMS) rapidly expanded access and payment for telehealth services (1). This facilitated clinical care for inpatients with COVID-19 while saving PPE, allowed outpatients with other chronic conditions who could not be seen in person to have a virtual doctor’s visit and limited losses for ID and other cognitive providers who would not have previously been paid for care delivered. Building access and flexibility is critical to extend future ID physician capacity, yet telehealth alone will not erase financial disincentives to careers in cognitive care. To grow the ID workforce, proposed programs offering student loan repayment or forgiveness opportunities and providing rapid financial relief for ID physicians and other frontline healthcare providers should be adopted. A diverse cognitive care workforce will be required to care for COVID-19 survivors who will have chronic respiratory and other complications long after their viral infection is gone (2). Career choices in medicine are influenced by personal experiences, interests, aptitudes, training, selective recruitment, loans, and physician payment. CMS must devote sufficient resources to ensure pricing and payment models do not jeopardize the nation’s health through promotion of a skewed workforce. Building the resources to meet the current and anticipated need for ID and other cognitive specialties requires Medicare payment policies that support the complex cognitive work of all at the future front lines. CMS has embarked on physician payment reforms that address longstanding distortions to outpatient evaluation and management (E/M) codes (3). Medicare’s Physician Fee Schedule must also be rebalanced, halting unneeded incentives for procedures to appropriately compensate the cognitively intense inpatient and outpatient work demanded ahead, for both COVID-19 and for the slow burning untreated chronic disease epidemic. The clinical demands of the COVID-19 pandemic – and CMS’s willingness to adapt quickly – have created innovative models for collaborative care delivery that highlight the urgency to develop a more robust physician payment structure. Rochelle P. Walensky, MD, MPH Daniel P. McQuillen, MD Sara Shahbazi, PhD John D. Goodson, MD References 1. Centers for Medicare & Medicaid Services. Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19. [Internet]. Baltimore (MD): 4/29/2020. Available from: https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf 2. Ahmed H et al. Long-term Clinical Outcomes in Survivors of Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) Coronavirus Outbreaks after Hospitalisation or ICU Admission: A Systematic Review and Meta-analysis. J Rehabil Med 2020;52:jrm00063. Epub ahead of print May 25, 2020 https://www.medicaljournals.se/jrm/content/abstract/10.2340/16501977-2694 3. Centers for Medicare & Medicaid Services. CY 2020 Medicare Physician Fee Schedule Final Rule, CMS-1693-P; 2019. [Internet]. Baltimore (MD) : Centers for Medicare and Medicaid Services; 2019. Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F Author, Article, and Disclosure InformationAuthors: Rochelle P. Walensky, MD, MPH; Daniel P. McQuillen, MD; Sara Shahbazi, PhD; John D. Goodson, MDAffiliations: Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (R.P.W., J.D.G.)Beth Israel Lahey Health–Lahey Hospital and Medical Center and Tufts University School of Medicine, Burlington, Massachusetts (D.P.M.)Massachusetts General Hospital, Boston, Massachusetts (S.S.)Financial Support: The work was supported by awards from the Massachusetts General Hospital Executive Committee on Research (Steve and Deborah Gorlin Research Scholars Award to Dr. Walensky).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-2684.Reproducible Research Statement: Study protocol: Available at https://usafacts.org/visualizations/coronavirus-covid-19-spread-map and www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier. Statistical code: Available from Dr. Shahbazi (e-mail, [email protected]). Data set: Available at https://usafacts.org/visualizations/coronavirus-covid-19-spread-map and https://data.cms.gov/Medicare-Physician-Supplier/Medicare-Physician-and-Other-Supplier-National-Pro/n5qc-ua94.Corresponding Author: Rochelle P. Walensky, MD, MPH, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Bul130, Boston, MA 02114; e-mail, [email protected] article was published at Annals.org on 3 June 2020. 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