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ExplainerEconomics

Why wRVU-only compensation models fail infectious disease

A payment system built to reward procedures measures a specialty built on cognition badly. What ID groups use instead.

7 min readGrowInfectiousDisease editorial

An empty hospital ward corridor at night, lit by low overnight lighting.

The short version

  1. 1Work RVU models capture billed encounters and miss stewardship, prevention, curbside consultation and coordination — much of ID's actual output.
  2. 2ID's institutional value is disproportionately in cost avoided rather than revenue generated, and avoided cost does not appear in a productivity report.
  3. 3Blended models — base plus productivity plus contracted service revenue plus measured quality — fit the specialty better than pure productivity.

Compensating an infectious disease physician on work RVUs alone is a category error. It measures the volume of billable encounters in a specialty whose value is substantially delivered outside them.

What the model cannot see

  • Antimicrobial stewardship — prospective audit, feedback, formulary and protocol work that reduces institutional drug spend and resistance pressure.
  • Infection prevention — outbreak response and policy work with direct regulatory and financial consequence for the institution.
  • Curbside consultation — high-volume, high-value, unbilled advice that changes management across other services.
  • OPAT coordination — weeks of monitoring and management per patient, generating few billable events relative to the work performed.
  • Diagnostic stewardship — reducing unnecessary testing, which reduces revenue elsewhere and is therefore invisible as a positive.

Each of these is a case where doing the job well produces less measured productivity, not more. A model that only counts wRVUs pays ID physicians least when they are doing the work only ID physicians can do.

The compensation context

National surveys have repeatedly placed infectious disease among the lowest-compensated specialties, and ID physicians report among the lowest levels of satisfaction with their compensation of any specialty surveyed — while overwhelmingly reporting they would choose the field again. Fellowship positions have gone unfilled for over a decade. Policy analysis has examined targeted payment adjustment as one lever for addressing the resulting shortage.

The relevance here is structural: a compensation model that undervalues the specialty's actual output contributes directly to a pipeline problem that then makes the remaining expertise scarcer.

What better models look like

  1. A meaningful base reflecting availability and the non-billable obligations the role carries.
  2. A productivity component on clinical work, sized so that it motivates without dominating.
  3. Contracted service revenue flowing through explicitly — directorship, stewardship, coverage — rather than being buried in the base.
  4. A measured value component tied to institutional metrics the program genuinely influences: antimicrobial expenditure, length of stay for defined conditions, readmission during OPAT, survey outcomes.

The fourth is the hardest to negotiate and the most important. It is the only component that pays for the work the other three cannot see.

Sources & further reading

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