Beyond the Bedside: Alternative Streams of Revenue for Infectious Disease Specialists

Infectious diseases traditionally has been a poorly compensated field of medicine. Many providers choose the field of ID for the intellectual stimulation and breadth of pathology, not the size of the paycheck. However, medicine is a business, so pressures and expectations to generate revenue exist. There are no specialty procedures “owned” by ID, and the currency of expertise is knowledge acquired from additional training and ongoing education. Because of this, seeing patients in the traditional settings (ie, clinic or the hospital) is not always enough to generate sufficient revenue as an ID provider compared with procedure-heavy fields, especially in the academic setting. This article will focus on 3 alternative sources of income for ID providers, including ID telemedicine/antibiotic stewardship, travel medicine, and clinical research.

ID Telemedicine/Antibiotic Stewardship

A silver lining of the COVID-19 pandemic was the scale-up and fine-tuning of telemedicine. A combination of sequester-at-home orders and fear of seeking medical attention forced the medical field to use telemedicine to continue providing care when in-office visits were not always an option. H.R. 6074 and multiple other legislative acts cut through red tape, expanded Medicare coverage of telehealth/telemedicine, and ultimately helped to bolster the success of implementing telemedicine for communities and populations that did not have access to telemedicine in the past.^1,2 With the end of the public health emergency (PHE) in May 2023, some provisions and waivers for telehealth/telemedicine also ended, but the infrastructure to continue telehealth/telemedicine coverage in many locations has remained.³

Telehealth is broadly defined as providing both clinical and non-clinical services remotely, whereas telemedicine specifically refers to providing clinical care remotely.⁴ For ID, the extent of this remote medical care varies and can range from antibiotic stewardship to ID electronic consultations (eg, chart review only) to virtual visits, where there is an audiovisual component and remote staff support to provide encounters that are considered comparable to an in-person visit with an ID specialist.

In 2017, it was estimated that 90% of counties in the United States had either below average or no ID physician coverage, and this disproportionately affected rural communities.⁵ This gap equated to more than 200 million people who were living in counties with minimal to no ID provider coverage. With only 67% of ID fellowship positions filled in 2023, the demand for ID physicians continues to outpace the supply, and this trend is predicted to continue over the next decade.⁶ Multiple studies have demonstrated the positive impact of ID consultation on various outcome measures including mortality, length of stay, and cost savings.^7-9 Furthermore, the literature has also shown that telemedicine, in general, allows for improved access to medical services and cost savings without compromising patient satisfaction or outcomes.⁴ What about combining the two—ID and telemedicine?

Overall, data show that ID telemedicine seems to be comparable to in-person consultation, with most studies showing no significant differences in clinical outcomes, and some data even showed decreased length of stay and lower rates of transfer to tertiary care facilities in patients who received telemedicine ID services.^10-12

While ID telemedicine can offer virtual/electronic consultations, antibiotic stewardship services are another valuable service that ID providers can deliver remotely. In response to the global crisis of antibiotic resistance, the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) require hospitals and nursing care facilities to have an antibiotic stewardship program (ASP). However, there is not a requirement that these programs must be on-site. For many smaller institutions, there is insufficient staffing to have an on-site ASP, which is where telemedicine stewardship programs can be valuable. Using remote ASPs not only satisfies the CMS/TJC requirements but also has been shown to decrease antibiotic use, antibiotic costs, and healthcare-associated Clostridioides difficile infections.^13-15

Offering telemedicine ID services can be mutually beneficial in bridging the increasing gap between the supply and demand of ID physicians. This, in turn, benefits patient populations who would otherwise not have access to an ID physician and benefits the ID physicians in providing an additional stream of revenue. Compensation for ID telemedicine services typically is through contracts or grants with community hospitals or hospitals within a multi-hospital health system. These contracts can and should be negotiated to meet the consultative/stewardship needs of a hospital but also to turn a profit for offering access to specialty care. While cost savings on antimicrobial use are published widely for ASPs, there is a paucity of data about the costs of implementing and maintaining an ASP.¹⁶ From pediatric data, annual estimated costs of an ASP can range from $17,000 to nearly $390,000.^17,18 Telemedicine implementation and maintenance costs are also not readily found in the published literature. Costs to consider when negotiating a telemedicine contract include equipment costs (which can range from $20,000 to nearly $100,000), initial connectivity costs (typically can range from $4,000 to $6,000), connectivity maintenance (variable costs), and annual service fee ($60,000 to $90,000 quoted for 1 telemedicine program).¹⁹

Both stewardship and telemedicine contracts bring in revenue for an ID division/group, and depending on the extent of the services offered, can allow for adjusted relative value unit (RVU) targets or RVU-generating work. For providers looking to create a new ID telemedicine program, Livorsi et al published an excellent road map in 2022, with a checklist for pre-implementation, implementation, and maintenance phases. Key considerations when developing a program include support from leadership and stakeholders, determining the extent of services to be provided, developing standard operating procedures, determining evaluation measures of program effectiveness, and assessing sustainability of the program.²⁰

Travel Medicine

The international tourism industry took a major hit from the pandemic, with an estimated 72% decrease from 1,465 million international tourists to 407 million from 2019 to 2020—over the course of just one year.²¹ However, with the end of the global crisis of the pandemic, international travel has ramped up and has almost recovered to pre-pandemic rates of travel, with approximately 285 million international travelers from January to March 2024.²² From the United States alone, there were more than 9 million travelers who departed for international destinations in March 2024.²³ With such a large potential patient base, offering travel clinic services, especially in non-urban settings where travel clinics are not always readily accessible, can be quite lucrative for ID physicians. A travel clinic can be a valuable resource to a community primarily through tailored patient-specific counseling. There is a plethora of accessible general information on the internet for travelers, but this information does not incorporate specific details of an itinerary or a patient’s individual medical history, which can significantly change potential exposure risks. Studies have shown lower incidences of travel-associated infections, including malaria, acute hepatitis, HIV, and diarrhea when patients receive pre-travel counseling.^24,25

Travel clinic visits often are not covered by insurance, so patients typically will pay for their visit costs up front and can submit for insurance coverage afterward. The main costs for upkeep of travel clinic services housed within an ID clinic are the costs of the vaccines to keep them in stock and a yearly subscription cost for a travel health database. The travel clinic visit itself consists primarily of counseling, providing any recommended travel-related vaccines as well as recommended age-appropriate vaccines, and providing any travel-related prescriptions, such as malaria prophylaxis or a pro re nata (PRN, as needed) treatment course for traveler’s diarrhea (when applicable). Travelers can also be offered follow-up services after travel for any potential travel-related illnesses.

In terms of potential revenue, each component of the travel visit is billable. The counseling fees can be billed as either individual counseling or group counseling. There is a discount for group counseling as the counseling portion of the visit is provided to multiple patients traveling together. The fee for counseling increases as the time spent on counseling increases. Most travel patients need a minimum of 30 minutes of counseling, but many often require 60 minutes. After counseling, the patient can receive any recommended vaccines. There is a separate cost for the administration of the vaccines as well as the cost of the vaccine itself. Vaccine prices fluctuate but, on average, are $100 to $200 per vaccine. This amount may vary depending on the vaccine and whether one or more doses are needed. Adding up these components, each travel visit can bring in hundreds of dollars that the clinic receives at the time of the visit. It has been estimated that travel clinics can provide up to a 30% “margin of opportunity.”²⁶

Clinical Research

Clinical trials comparing investigational drugs and standard-of-care treatments are the basis for progress in the field of medicine. Nowhere is this truer than in the ID field, and this phenomenon crystallized during the COVID-19 pandemic. Clinical trials come in 2 varieties: government studies (eg, National Institutes of Health [NIH]) or pharmaceutical companies’ research. There is potential for revenue in either type, but one must be very careful because clinical trials are labor-intensive.

Whether in the academic or private practice setting, there is always overhead associated with clinical trials. In the academic setting, NIH trials typically have an overhead of 50% or higher; for pharma studies overhead, these indirect costs frequently are in the range of 30% to 35%. These costs are for clinic space and contract negotiations. An efficient and profitable clinical trials program requires personnel, usually one or more nurses (RN level), who must be knowledgeable about the protocol as well as the concept of Good Clinical Practice.

Clinical trials are very different from clinical practice. In clinical practice, a provider can change medications whenever he or she chooses. Not so in clinical trials: The provider must know the protocol and must follow the protocol. Any deviation from the protocol will be scrutinized by the clinical research organization (CRO), and the provider will need to explain the deviation. The CRO will meet periodically with the clinical trials personnel, including the principal investigator. These meetings take time, and time is money.

A good clinical trials program will enroll a reasonable number of subjects (patients) to make the effort profitable. If the trial does not enroll an adequate number, then the trial may lose money. The ability to predict how many subjects that can be enrolled is key to making a clinical trial profitable for the practice.

Conclusion

The practice of ID care has changed dramatically over the past several decades. The care of HIV patients, the fight against antimicrobial resistance, and the promotion of good antimicrobial stewardship define the roles of the ID clinician. Medical schools do not train students to be businesspeople. Nevertheless, medicine has become a business, and it behooves all of us to try to learn what we can so that we can swim with the sharks rather than sink to the bottom.

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About the authors:

Jennifer Emberger, MD, MPH, is the co-medical director of the School of Physician Assistant Studies, co-program director of the Global Health and Underserved Populations Program and a clinical assistant professor of medicine, at the Brody School of Medicine at East Carolina University, in Greenville, North Carolina.

Paul P. Cook, MD, FACP, FIDSA, is the chief of the Division of Infectious Diseases, at the Brody School of Medicine at East Carolina University, in Greenville, North Carolina.

Drs. Emberger and Cook reported no relevant financial disclosures.

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Beyond the Bedside: Alternative Streams of Revenue for Infectious Disease Specialists

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