Changes are needed on all sides—insurers, the government, and physicians—to eliminate financial barriers for getting children recommended vaccines, according to Dr. Jon R. Almquist.
On the reimbursement side, some private insurers are taking too long to agree to cover vaccines once they've been recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP), said Dr. Almquist, who coauthored an article about reducing financial barriers to vaccination; the article appeared in a special supplement to Pediatrics focusing on vaccine issues (Pediatrics 2009;124:S451-4).
“We've got documentation that physicians very commonly hold back [on giving a particular vaccine] because they don't know whether private industry is covering that vaccine yet,” said Dr. Almquist, who is a member of the National Vaccine Advisory Committee. “And when the physician gives the patient a vaccine and the insurance company rejects [coverage for] it or pays for a similar vaccine that costs significantly less, those things make a huge problem for the physician.”
Dr. Almquist explained that once ACIP recommends a vaccine, some time elapses—occasionally 6 months or sometimes more—until the announcement of the recommendation is printed in the Morbidity & Mortality Weekly Report, a publication of the Centers for Disease Control and Prevention. Part of that delay is to give the CDC time to negotiate contracts with manufacturers of the new vaccine. But once the announcement is in the MMWR, the vaccine is now covered under the federal Vaccines for Children (VFC) program and available for states to obtain for their VFC-eligible patients. It is at this point that private insurers usually begin to act.
“The insurance industry has had variable responses” to the MMWR publication, he continued.
For example, some insurers automatically cover whatever vaccines ACIP recommends, while others send the recommendation to an internal review board for approval, which can delay things further.
Delayed coverage by private insurers is problematic because the VFC program always covers new vaccines right away. “The providers have said, ‘It's really a problem having children in the Vaccines for Children program getting the vaccine [from us] when we can't give it to privately insured patients; we're treating people differently and that sets us up for a lawsuit,’” said Dr. Almquist, who recently retired from private practice. “If a child gets a disease and we didn't give them the vaccine, we can end up on the wrong end of the legal system.”
Recent data from America's Health Insurance Plans, an industry trade group, showed that the average time that elapses between a vaccine's announcement in the MMWR and private insurers beginning to cover the vaccine has dropped from 3 months to 1 month, “which is really good,” Dr. Almquist added. And although insurers did not want to see vaccine coverage mandated by federal or state government, they did agree to make first-dollar reimbursement for ACIP-recommended vaccines a “voluntary standard” for the industry, he said.
Another problem for physicians is the variance in reimbursement rates for vaccines. Three studies included in the supplement showed large variations in what insurers reimbursed physicians for a particular vaccine—“sometimes they paid less than the cost of the vaccine itself, and sometimes they paid twice as much as what the vaccine cost,” said Dr. Almquist, who is also chair of a subcommittee on immunization at the American Academy of Pediatrics. One study in the supplement by Dr. Gary Freed and his colleagues at the University of Michigan, in Ann Arbor, found that the maximum and minimum reimbursements for a single vaccine differed from $8 to more than $80 (Pediatrics 2009;124:S459-65).
But physicians themselves also shouldered some of the blame because some of them paid very high prices to purchase the vaccines in the first place, Dr. Almquist noted. The study by Dr. Freed and his colleagues found that “there was a considerable difference between the maximum and minimum prices paid by practices, ranging from $4 to more than $30” for specific vaccines, according to the authors.
“What we found is that physicians are pretty lousy business people,” said Dr. Almquist. “Sometimes they were paying more than what the spot price was if they just went to the Internet and paid dose by dose.” In their article, Dr. Almquist and his colleagues recommend that physicians use purchasing groups to buy their vaccines, and that they negotiate with insurers for better payment rates for both vaccines and administration of vaccines.
The reimbursement rate for vaccine administration needs to include the costs involved in administering vaccines—things like counseling, documentation, and labor, Dr. Almquist said. Several studies in the supplement looked at the reimbursement issue using different methods, but they all came up with very similar figures, he said. In one such study, Judith E. Glazner of the Colorado School of Public Health, in Aurora, and her colleagues found that the total variable cost per vaccination averaged $11.51; for two vaccinations, more than one-third of health plans paid physicians less than the combined variable cost of $23.02. The authors noted that “more than one-third of the [insurer] payment agreements paid the practices less than the combined variable costs for two immunizations” (Pediatrics 2009;124:S492-8).
Given the problems physicians have being adequately paid for the administration of vaccines, the federal government should pay the entire cost of vaccine administration under the VFC program, rather than leaving some of the cost to be paid by the states, according to Dr. Almquist and his colleagues. “The amount paid for administration for Medicaid-covered children runs between $2 and $18, and it's a big-time issue. Some states pay a significant amount, and others contribute almost nothing,”
Although paying the entire administration fee would cost the federal government “a big chunk of change”—an estimated $800 million, with savings to states of $300 million—it would be well worth the investment, he added. “Everybody agrees that immunization is one of the most cost-effective things we can do for the health of this nation.”
The Pediatrics vaccine supplement issue is available free online at http://pediatrics.aappublications.org/content/vol124/Supplement_5.
FULL TEXT