{"id":5992,"date":"2015-04-22T10:01:58","date_gmt":"2015-04-22T14:01:58","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=5992"},"modified":"2019-11-21T13:49:17","modified_gmt":"2019-11-21T18:49:17","slug":"seriously-how-much-would-you-pay-for-a-curbside-consult","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/seriously-how-much-would-you-pay-for-a-curbside-consult\/2015\/04\/22\/","title":{"rendered":"Seriously — How Much Would You Pay for a Curbside Consult?"},"content":{"rendered":"

\"ron<\/a>Yes, seriously.<\/p>\n

Let me start with an email exchange I had with a PCP recently:<\/p>\n

Hi, Paul, quick question \ud83d\ude09 This lady, 49 YO woman from Haiti, asymptomatic, totally healthy. Got TSpot done for immigration purposes, it’s\u00a0positive with\u00a0negative chest Xray. Treated with INH 6 months in 2001. She travels to Haiti annually so\u00a0could had been reexposed, though doesn’t report being with anyone with TB. Do I need to treat her again? THANKS!
\nCarla<\/span><\/p>\n

To which I responded:<\/p>\n

Hi Carla, unless there’s been a significant re-exposure and immunosuppression, no need to re-treat.
\nPaul
\np.s. You know we could start getting paid\u00a0for these “eConsults.” How much do you think they\u00a0are worth?<\/p>\n

So it’s now Carla’s turn to answer my question:<\/p>\n

Priceless!!!! Seriously, not sure, since some questions are more complicated than others.\u00a0Sometimes it’s straightforward like this, and sometimes you have to review more data so that should be compensated more no?<\/p>\n

Carla helped me out here, especially with her first response — priceless indeed.<\/em> But the second part — where she suggested that this “straightforward” question\u00a0is worth less a more complex one — hints at why estimating the value of these consults is so difficult.<\/p>\n

And it’s important that we figure it out, and soon.\u00a0With the inevitable move to\u00a0“value-based” insurance contracts<\/a>, many ID doctors\u00a0are getting\u00a0the push\u00a0to formalize these clinical relationships. That’s a good thing, as\u00a0clearly getting advice from a\u00a0colleague can be a more efficient way to provide quality care than referring everyone for a formal consultation, and it\u00a0puts a value on\u00a0what previously was almost always done gratis.<\/p>\n

Back to the question in the email — is it so straightforward? Clearly not to Carla, who as a generalist has to manage all<\/em> medical problems not just ID ones, but to us brilliant ID doctors, sure.\u00a0An IGRA (the T-Spot) and tuberculin skin test are basically two different ways of looking at the same thing (evidence of immune response to TB), and I’ve already been asked this question (or one like it)\u00a0several times. Plus, I can touch-type (as I’ve bragged elsewhere, I could crank out\u00a0over 70 words\/minute in my 8th grade typing class), and happened to be sitting at my desk daydreaming about puppies playing baseball<\/a> when the email popped into my in box.<\/p>\n

Even if you account for the distraction factor — it was hard to get that puppy image back — it still took\u00a0only a few minutes.<\/p>\n

And as I’ve calculated before, if paid on an hourly basis, this comes out at a whopping $6\/consult,<\/a>\u00a0or almost enough for a couple of\u00a0fancy\u00a0coffees at Starbucks. If we believe the good news from this latest Medscape salary survey<\/a>\u00a0that ID doctors are no longer in the basement when it comes to annual salaries — sorry, pediatricians — we’re only up to $8\/consult\u00a0(add\u00a0a bagel\u00a0to your coffee order).<\/p>\n

So when it comes to curbsides, if you pay by time\/consult, we ID doctors could be\u00a0in deep trouble — the faster we\u00a0do it, the less time-value it has, and the less we make. It’s quite different with\u00a0surgeons — they get paid\u00a0more<\/em>\u00a0with greater experience and efficiency.<\/p>\n

Furthermore, though the fee-for-service model is horribly broken for ID as a specialty — no way to win on either volume or procedures — our clinical productivity is still\u00a0mostly\u00a0measured by\u00a0how many patients we actually see. Every curbside we do is potentially a patient visit that didn’t happen. Note again how we differ from surgeons and other procedural specialists — from a revenue perspective, they have an incentive to keep simple non-operative cases out of their clinics.<\/p>\n

Finally, the consultant is taking on some non-zero medicolegal risk. Should that be somehow factored into the compensation? In this excellent review<\/a> — which is very pro-curbside — the author states that courts have consistently concluded that there is no actual medicolegal risk to the person being curbsided provided there is no relationship between him\/her and the patient.<\/em> However, he also accurately states: “Of course, even in the absence of actual liability,\u00a0there is always a possibility that the consulted physician will\u00a0be sued for medical malpractice. Although such a physician\u00a0should ultimately prevail as a matter of law, the entire\u00a0process is best avoided\u00a0<\/strong>[emphasis mine].” Hard to disagree!<\/p>\n

Other payment models are out there for informal consults, such as getting a flat rate\u00a0per consult regardless of complexity (how much?), or getting a percentage of your salary covered for being “on call” for this service (what percentage?). And of course many will still have to live\u00a0with the status quo of getting nothing — gratitude counts for something.<\/p>\n

Provided, of course, it doesn’t end with (pet-peeve alert) “Thanks in advance!<\/strong><\/a>”\u00a0<\/em>A simple “Thanks” is perfectly fine.<\/p>\n

Now, how much would you pay?<\/p>\n

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How much should an ID doctor be paid for a curbside consult?<\/strong><\/p>