Pricing the work you are already giving away: hospital coverage and stewardship

The most under-priced asset in most independent ID practices is not a service line. It is the accumulated set of institutional obligations the group absorbed one favour at a time.

Why the hospital's position is stronger than you think — and weaker

Hospitals require antimicrobial stewardship programs and infection prevention capability as a condition of participation and accreditation. That is not a preference; it is a compliance requirement with a named physician leadership expectation attached. The institution needs qualified ID physicians to sign, lead and be accountable.

At the same time, ID is a specialty in documented workforce contraction. Fellowship positions have gone unfilled year after year, and compensation sits near the bottom of specialty surveys — a combination that produces exactly what you would expect: fewer ID physicians, concentrated in fewer places. Policy researchers have explicitly examined targeted payment adjustments as a response to the shortage.

The practical read: you are supplying something the institution is required to have and the market is producing less of. That is a legitimate negotiating position, and it is one that ID physicians systematically decline to use.

Count the hours first

Before any conversation, document what is actually being provided over a representative period. Not an estimate — a log.

• Stewardship committee time, protocol development, formulary review, prospective audit and feedback.
• Infection prevention committee participation, outbreak investigation, policy review.
• Call coverage: hours on call, calls received, in-person response requirements.
• Educational obligations: residents, fellows, nursing, pharmacy.
• Administrative and regulatory support: survey preparation, reporting, quality metrics.

The log is the entire negotiation. An unquantified claim that "we do a lot for the hospital" cannot be priced; ninety documented hours a quarter can.

Separate the four agreements

Bundling everything into one number is how obligations expand without compensation following.

1. Medical directorship — a defined role, defined hours, defined deliverables, reviewed annually.
2. Stewardship program leadership — separately scoped, because it is separately mandated and separately resourced.
3. Coverage agreement — availability, response times and the boundaries of the obligation, priced as availability rather than as work performed.
4. Clinical consultation — billed to payers in the ordinary way, and explicitly excluded from the fee arrangements above so that nothing is paid for twice.

Compensation arrangements between physicians and hospitals sit within physician self-referral and anti-kickback frameworks, including fair market value and commercial reasonableness requirements. These agreements should be structured with healthcare counsel and, where appropriate, supported by an independent valuation.

Build in the scaling clause

The failure mode is not a bad initial number. It is a good initial number attached to an obligation that grows for five years while the fee does not. Include a defined scope, a review cadence, and a mechanism for renegotiation when volume or obligation changes materially. Write down what triggers the review before you need it.

On making the value case

Institutions respond to institutional metrics. Where your program can evidence reduced length of stay, avoided readmissions, antimicrobial expenditure reduction, resistance-pattern improvement or successful survey outcomes, those are the terms in which the argument lands. Clinical excellence is assumed; measured institutional impact is what gets funded.