The stakes could hardly be higher. Populations across Europe and much of the world are aging at an unprecedented pace, yet geriatric medicine consistently struggles to recruit new specialists. International surveys have documented a paradoxical decline of geriatric medicine as a profession in some countries, and workforce projections point to a looming geriatrician shortage that threatens the quality of care for older adults precisely when demand is rising fastest. In the United States, the National Resident Matching Program data reveal persistently unfilled positions in geriatrics, while European analyses of medical education show that many countries offer little or no undergraduate exposure to the discipline. Against this backdrop, understanding why the doctors who do choose geriatrics make that choice is a question of urgent practical importance.

The Spanish research team, led by investigators from hospitals including Hospital Universitario de La Ribera, Gregorio Marañón University Hospital, Navarra University Hospital and Ramón y Cajal University Hospital, approached the question with a qualitative descriptive design. Rather than testing a hypothesis with a randomized experiment, the researchers used intentional sampling and distributed an anonymous questionnaire to residents in accredited Spanish geriatric teaching units. The methodology reflects the exploratory nature of the question: career choice is a deeply personal phenomenon shaped by experiences, emotions and values that are difficult to capture with a purely quantitative instrument. By asking open-ended and structured questions together, the team was able to identify which factors residents themselves report as decisive.

The demographic and educational profile of the participants itself revealed something notable. Eighty-nine per cent of the residents said they were already familiar with geriatric medicine before entering their specialty training, and 46 per cent had received both theoretical and practical training in geriatrics during their medical degrees. This distinction proved to be statistically meaningful. Residents who had received complete training in the specialty — meaning both classroom instruction and hands-on clinical experience with older patients — were significantly more likely to have considered geriatrics as a potential career path before choosing it. Among the fully trained group, 75 per cent had considered geriatrics as a potential specialty, compared with only 54 per cent of those without such training, a difference the researchers report as statistically significant with a p-value of 0.02.

Even more striking was how training changed the way residents viewed the clinical content of their work. The clinical complexity of older adult patients — the intricate interplay of multimorbidity, atypical disease presentation, frailty, polypharmacy and functional decline that defines geriatric medicine — was rated as a relevant factor by 92 per cent of those with complete geriatric training, compared with 77 per cent of those without it (p = 0.027). In other words, far from being deterred by complexity, residents who had been properly taught geriatrics embraced it as one of the most intellectually stimulating aspects of the field. What many medical students perceive as a barrier — the messy, multi-system, challenging nature of older patients — appears to be reframed by good training into a source of professional satisfaction.

The ranking of motivating factors tells a vivid story about what draws people to this specialty. The most frequently cited factor, reported by 95 per cent of participants, was affinity with older persons. Close behind came communication with patients and families at 90 per cent, and multidisciplinary work at 86 per cent. The clinical complexity of older adults followed at 84 per cent, multimorbidity at 82 per cent, and — notably personal — relationships with older relatives at 76 per cent. This last figure underscores how biographical experience shapes career decisions: many residents explicitly connected their professional choice to grandparents, parents or other older people in their own lives. The pattern suggests that geriatrics attracts physicians who value longitudinal human relationships, teamwork and the intellectual challenge of patients who cannot be reduced to a single organ system.

These findings align closely with a growing body of international evidence. A French national survey of postgraduate medical students published in Age and Ageing found similar themes of human connection and clinical interest, while a Danish survey of junior doctors published in European Geriatric Medicine in 2025 examined the same question from a Northern European perspective. A British survey of UK specialist trainees likewise identified the rewarding nature of the work as a central attraction, in contrast to the perception that geriatrics lacks earning potential and prestige — a perception that has long been documented among medical students and identified in systematic reviews as one of the reasons medical students avoid the field. The hidden curriculum, in which elderly patients are sometimes subtly portrayed as less interesting or less rewarding to treat, has been shown to influence student attitudes in ways that formal teaching must actively counteract.

What distinguishes the Spanish study is its direct measurement of the training effect. Previous research has documented that undergraduate geriatric education varies enormously worldwide — a narrative overview of undergraduate geriatric medicine education found stark differences in curricula, teaching hours and clinical exposure across countries, and scoping reviews have mapped a changing landscape of geriatric curricula, topics and teaching methods. The Spanish findings now provide concrete evidence that the extent of this training is not merely correlated with career choice but appears to function as a mechanism: comprehensive education in geriatric medicine seems to transform the perceived difficulty of geriatric patients into an appealing professional challenge. This has immediate policy implications, because it suggests that expanding mandatory geriatric content in medical school curricula could be one of the most effective levers for addressing the workforce crisis.

The significance of this lever becomes clear when one considers the demographic mathematics. According to the United Nations World Population Prospects 2024, the proportion of adults aged 80 and above is rising steadily across Europe, and Eurostat data confirm that the European Union’s population structure is shifting year by year toward ever-larger cohorts of the very old. Spain itself has one of the fastest-aging populations on the continent, and the Spanish health system’s own indicators track this transformation. Geriatric medicine, as defined in position statements by the European Union Geriatric Medicine Society and refined in recent Lancet Healthy Longevity work on the role and reach of the geriatrician, is fundamentally about comprehensive geriatric assessment — a multidimensional, interdisciplinary diagnostic process that evaluates medical, psychological and functional capability in order to develop coordinated care plans. Teaching this approach requires both theoretical grounding and supervised clinical practice, which is precisely the combination that the Spanish study identifies as transformative.

The researchers are careful to note the limitations inherent in their design. As an anonymous survey of residents who had already chosen geriatrics, the study captures the motivations of those who entered the specialty rather than those who rejected it, and self-reported questionnaires are always subject to recall and social desirability bias. The intentional sampling within a single national system limits generalizability, and the qualitative descriptive approach, while rich in detail, cannot establish causation between training exposure and specialty choice with the certainty of an experimental design. Ethical approval was not required under applicable Spanish institutional and national regulations because the study involved an anonymous voluntary survey of healthcare professionals with no patient data, and participation was voluntary with consent implied by questionnaire completion.

Nevertheless, the study’s central message is both simple and actionable: interest in geriatric medicine is shaped by a combination of personal motivations and factors directly related to the specialty and the characteristics of the older adult population, and comprehensive training has the potential to transform commonly perceived barriers into rewarding aspects of the field. For medical schools, this means that the question is not whether geriatrics can attract talent, but whether curricula give students a genuine chance to discover what the specialty actually involves. For health policymakers facing aging populations and shrinking geriatric workforces, the Spanish experience suggests that investment in undergraduate geriatric education may pay dividends far beyond the classroom — in the form of a new generation of physicians who see the complexity of the oldest patients not as a burden to be avoided, but as the most stimulating and meaningful work medicine has to offer.

Recognizing this alarming trend, the Centers for Medicare and Medicaid Services (CMS) has taken an unprecedented step by introducing the first specialty-specific add-on payment code within the Medicare Physician Fee Schedule. Effective in 2025, this new provision, designated G0545, supplements reimbursement for inpatient infectious disease consultations by approximately 20%, reflecting not only the complexity of ID services but also CMS’s acknowledgment of the urgency to reverse workforce decline. This move marks a pivotal shift in federal health policy, signaling a nuanced understanding that adequate compensation must align with clinical expertise and public health value.

Historically, federal reimbursement models have largely applied across-the-board fee adjustments or broadly targeted specialties with widespread shortages without tailoring incentives to specific disciplines. This new CMS add-on code departs from such conventions by directly tying additional payments to the unique responsibilities handled by ID physicians—ranging from intricate risk mitigation for disease transmission, comprehensive public health investigations, advanced laboratory analysis, to nuanced antimicrobial counseling and treatment strategies. This degree of specificity in reimbursement design could set a transformative precedent for physician payment policy.

Researchers from the Harvard Pilgrim Health Care Institute conducted a rigorous analysis of this novel payment model, published in the June 2025 edition of JAMA. Their work underscores both the promise and the challenges inherent in this pioneering federal initiative. According to the study’s lead investigators, while the increase in reimbursement is substantial relative to historic compensation benchmarks, it remains to be seen whether these add-on payments will effectively translate into enhanced salaries for ID physicians rather than merely bolstering hospital revenue streams. The latter scenario risks failing to address the core disincentive that has deterred entry into the specialty.

Moreover, infectious disease specialists often shoulder responsibilities that extend well beyond direct patient care, including critical roles in antimicrobial stewardship programs that combat antibiotic resistance—a global health threat that births strains of bacteria impervious to existing drugs. They also play an indispensable role in pandemic preparedness and response, their expertise often guiding policy decisions and clinical protocols during outbreaks. Current compensation mechanisms, however, have inadequately reflected these multilayered contributions, fostering a disconnect between the demands of the specialty and the financial rewards it yields.

An additional complicating factor highlighted by the researchers is the geographic maldistribution of infectious disease physicians. Rural and underserved regions suffer disproportionately from shortages, contributing to stark disparities in health outcomes related to infectious diseases. The CMS add-on code, while a critical initial step, does not yet integrate location-sensitive adjustments that could incentivize deployment of ID specialists to these high-need areas. Recognizing this gap, the Harvard Pilgrim team advocates for augmenting the add-on payments with differential rates based on geographic and demographic criteria to strategically steer workforce allocation.

The study also calls for a framework of accountability and transparency to ensure that increased reimbursements meaningfully impact physician income. Hospitals and health systems are currently positioned to bill using the add-on code, yet without explicit mechanisms for verifying that these funds are passed through to the specialists themselves, the intended incentive effect could be diluted. The researchers propose that CMS incorporate auditing and reporting requirements tied to physician compensation, analogous to the practices employed in monitoring New Technology Add-on Payments, fostering trust that financial incentives are properly channeled.

Beyond immediate pay adjustments, the policy architects and researchers alike emphasize the importance of viewing this add-on code as a pilot program—a deliberate experiment subject to careful monitoring, data collection, and outcome evaluation. This iterative approach would help CMS and other stakeholders gauge the efficacy of such targeted reimbursement strategies in mitigating specialty shortages before scaling or adapting the model to other clinician groups facing similar challenges. Metrics such as changes in filled fellowship positions, physician retention, patient access, and health outcomes will be pivotal in this evaluative phase.

The implications of this initiative extend beyond the infectious disease specialty itself. Because Medicare reimbursement rates frequently anchor commercial payer fee setting, an upward adjustment in ID compensation under Medicare has the potential to recalibrate nationwide payment standards. This could signal a broader recalibration of how physician services are valued, particularly in specialties characterized by complex, high-risk clinical work that is not adequately captured by conventional billing codes. The researchers view this as an opportunity to realign financial incentives with contemporary healthcare needs and public health priorities.

While the new add-on code is certainly a promising policy innovation, the Harvard Pilgrim analysis underscores that remedying physician shortages demands a multi-faceted strategy encompassing compensation, workforce distribution, educational support, and systemic recognition of specialty-specific contributions. Only through coordinated policy action, transparency measures, and ongoing assessment can the longstanding undervaluation of infectious disease expertise be effectively reversed, ensuring robust access to specialist care in a landscape defined by emerging infectious threats and evolving healthcare complexities.

As the United States faces an uncertain infectious disease horizon marked by emerging pathogens and persistent antimicrobial resistance, strengthening the infectious disease physician workforce becomes not only a matter of clinical necessity but one of public health and national security. CMS’s add-on payment initiative represents a foundational step in this direction, yet its ultimate success will hinge upon sustained commitment to equitable, targeted reimbursement policy, careful performance evaluation, and responsive adaptation to observed outcomes.

In their concluding remarks, the Harvard Pilgrim team imparts a clear message to policymakers and healthcare leaders: Infectious disease specialists possess unique and indispensable expertise that justifies higher compensation commensurate with their impact on patient care and population health. However, translating reimbursement policy changes into tangible improvements in workforce stability and patient health outcomes requires vigilant implementation and accountability. Without this, the ongoing shortage will persist, undermining the healthcare system’s capacity to respond adeptly to infectious disease challenges.

This novel federal reimbursement strategy thus stands at a crossroads, with the potential to reconfigure how specialized medical expertise is recognized and rewarded within the U.S. health system. Its trajectory will be closely watched by clinicians, hospital administrators, and policymakers alike, as it may herald a new era in tailored physician payment reforms designed to sustain critical specialties integral to the health security of the nation.

Subject of Research: Infectious Disease Physician Workforce and Medicare Reimbursement Policy

Article Title: Raising Reimbursement Rates to Combat Specialty Physician Shortages: A New Federal Initiative

News Publication Date: 25-Jun-2025

Web References: Harvard Pilgrim Health Care Institute Department of Population Medicine

References: Yu, H., Ramesh, T., et al. (2025). Raising Reimbursement Rates to Combat Specialty Physician Shortages: A New Federal Initiative. JAMA, June 25, 2025.

Keywords: Health care policy, Health care costs, Health care delivery, Insurance, Public finance, Clinical medicine, Infectious diseases, Health and medicine