Do You Have a Minute? Asking Infectious Diseases Clinicians to Provide Uncompensated Services
ID clinicians must be paid for time spent conducting unbillable work for OPAT services.
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Outpatient parenteral antimicrobial therapy (OPAT) services are becoming more widespread across the US to improve transitions of care for patients requiring intravenous (IV) antibiotics outside the hospital setting.1 Common disease states requiring IV antibiotics at discharge include endocarditis, bone and joint infections, and abscesses.
Study data on the effects of OPAT services consistently demonstrate their value regarding improved patient outcomes and lower health care costs. A publication in 2023 reported that approximately 40% of infectious diseases (ID) physicians in the US reported having a formal or dedicated OPAT program. The Infectious Diseases Society of America supports OPAT programs, characterizing them as “core quality indicators.” ID physicians, nurses, and pharmacists typically lead these services. Unfortunately, ID providers’ salaries are on the lower end of the spectrum compared with other specialties,2-5 despite saving money for systems. Yet ID clinicians often conduct unbillable work to provide OPAT services. Therefore, the time spent doing these activities must be quantified so clinicians receive appropriate compensation for their time.
Clinicians from the University of North Carolina recently published a brief report on their OPAT program, which serves their affiliated academic hospital and ID clinic.6 An ID pharmacist and an advanced practice nurse lead their OPAT service. They manage patients who are discharged with an OPAT plan to the home setting but not nursing facilities and follow approximately 40 to 50 patients at any given time.
The researchers evaluated “OPAT time” for patients on the OPAT service between 2020 and 2022. OPAT time was defined as uncompensated time spent providing OPAT management and coordination outside clinic time (eg, monitoring and communication). There were 1064 OPAT courses with OPAT time documented, with most conditions being related to bone and joint infections, followed by diabetic foot infections, intra-abdominal infections, or endovascular infections. The median duration for OPAT was 35 days (IQR, 24-40), and more than half the patients had 1 or no outpatient clinic appointments.
The researchers found a 19% readmission rate within this population. Median weekly OPAT time per OPAT course was 27 minutes (IQR, 19-39 min), with more time typically spent on patients receiving vancomycin than on those not receiving vancomycin (median, 40 vs 23 min). Based on the results of this study, along with others that have shown the workload and cost savings of OPAT teams, the authors concluded that OPAT clinicians spend significant amounts of uncompensated time serving these complex patients. Hospital systems must work with payers to find ways to bill for these services.
The authors noted that limitations in their study include the underrepresentation of time spent managing OPAT activities and that pharmacists and nurses (who lead their team) are clinicians who don’t regularly bill for services. They also did not include data for patients discharged to facilities, where many patients complete their OPAT. Two points can be taken from this study: All clinicians should be compensated appropriately for their time, and all clinicians should be able to bill payers for services. ID clinicians have a wealth of knowledge that they use to manage complex patients, which should be accounted for in billing structures. Study findings published in 2023 by clinicians in Vancouver, Canada, reported the results of an incentive-based policy for OPAT. The authors evaluated whether introducing an incentive for providers would increase OPAT use. They concluded that there was no significant increase in OPAT use after the policy was put in place. This could indicate that money does not incentivize providers to make changes to improve patient care; that even without incentives, they are doing as much as possible. Alternatively, the incentive offered may not have interested clinicians, or the barriers to increasing OPAT services may have related to too few personnel compared with lack of compensation.7
Future evaluations of OPAT programs might include an economic analysis of costs avoided related to improved transitions of care, improved patient outcomes, shorter length of stay, and reduced readmissions. These can be evaluated with the time and level of care spent outside billable hours. Analyzing cost avoidance along with levels of appropriate compensation based on time spent on OPAT services would allow administrators and payers to determine the value of OPAT clinicians.
Featured article:
Schranz AJ, Swartwood M, Ponder M, et al. Quantifying the time to administer outpatient parenteral antimicrobial therapy: a missed opportunity to compensate for the value of infectious diseases. Clin Infect Dis. Published online May 14, 2024. doi:10.1093/cid/ciae262
References
1.Shah AB, Norris AH, eds. OPAT EHandbook. 3rd ed. Infectious Diseases Society of America; 2016. Accessed August 5, 2024. https://www.idsociety.org/journals--publications/opat-e-handbook/
2.Larnard J, Swords K, Taupin D, Padival S. From sea to shining IV: the current state of OPAT in the United States. Ther Adv Infect Dis. 2023;10:20499361231181490. doi:10.1177/20499361231181486
3.Lee YJ. “It’s hard to pay off your medical school loans in this kind of a job”: Doctors who can protect the world against pandemics are in short supply. Business Insider. Accessed July 24, 2024. https://www.businessinsider.com/infectious-disease-specialists-short-supply-low-paid-doctors-us-2020-5
4.New doctors aren’t choosing to go into infectious disease. https://www.npr.org/2022/12/13/1142594197/new-doctors-arent-choosing-to-go-into-infectious-disease. 2022. Accessed August 5, 2024.
5.Heys J. IDSA Treasurer: ID specialists are critical to the health preparedness workforce but need support. June 22, 2023. Accessed July 24, 2024. https://www.idsociety.org/science-speaks-blog/2023/idsa-treasurer-id-specialists-are-critical-to-the-health-preparedness-workforce-but-need-support/
6.Schranz AJ, Swartwood M, Ponder M, et al. Quantifying the Time to Administer Outpatient Parenteral Antimicrobial Therapy: A Missed Opportunity to Compensate for the Value of Infectious Diseases. Clin Infect Dis Off Publ Infect Dis Soc Am. Published online May 14, 2024:ciae262. doi:10.1093/cid/ciae262
7.Staples JA, Ho M, Ferris D, et al. Physician Financial Incentives for Use of Outpatient Intravenous Antimicrobial Therapy: An Interrupted Time Series Analysis. Clin Infect Dis. 2023;76(12):2098-2105. doi:10.1093/cid/ciad082
