Slowly Turning Tide

Vaccines may be saving the lives of children, but they are killing the docs who give them. Pediatricians have to pre-purchase tens or hundreds of thousands of dollars of vaccines, insure them while they sit in the fridge, and then are often paid at or less than what they paid for the vaccines themselves when administered weeks later. If a mom changes her mind after the imm has been drawn or the kid fights it – there’s $75 down the drain. Gardasil is a great example: many insurers still don’t cover it fully! – so the practice is supposed to eat the few hundred bucks? Or, how about the flu vaccines? Patients fill the phone lines of the offices looking for a shot…that the docs can’t fill until after the rush is over…meanwhile, Wal*Mart and the retail clinics often got their deliveries on time.

That just makes no sense. Enough pediatricians are feeling the pinch, however, that we’re seeing movement. One solution is to check out the numerous vaccine buying collectives (Physician’s Alliance, Pediatric Federation, and Main Street Vaccines come to mind).

To the AAP‘s credit, this is one issue they are doing something about. I just hope they can do something in time.

Meanwhile, here’s a summary [link dead] of the problem from the latest issue of Infectious Diseases in Children. It provides more data to match the vignettes from that NY Times piece from a few weeks ago (featuring PCC clients and friends alike). In the IDC article, they recommend:

  • Fix vaccine administration fees; this includes collecting data on the costs of delivering vaccines in private practices, getting support on methodology from the Centers for Medicare and Medicaid Services and using the data to educate insurers and Medicaid on appropriate reimbursement.
  • Work with vaccine manufacturers to obtain more favorable terms for the initial inventories of new vaccines.
  • Work with federally qualified health centers to delegate authority to serve underinsured children through the Vaccines for Children Fund at public health department clinics.

..which is a pretty good list, if you ask me. Yes, there are other changes I’d recommend, including:

  • Simplifying the coding process. I know practices who still don’t even use the 90465/6 codes (spoke to one today!) for reasons of half-legit voodoo: it wasn’t getting paid for the first 6 months, they don’t understand it, etc.
  • Mandate a clear process for providers to follow once a vaccine has been approved. To make a long story short, the practices routinely run into circumstances where a vaccine is “recommended” months before payment is approved from the insurance companies. And, once payments come in, they are below provider costs (or don’t meet the 25% margin they need not to lose money).
  • Provide contractual protection to providers who would like to give a vaccine but do not wish to suffer from the lagging payments of the payors. In other words, if Merck decides that the price of Vaccine A needs to go up by $25 or Vaccine X is now recommended by ACIP or the AAP or whatever, allow the practices to collect the price difference from the patients during the 3-6 months it takes for the payors to fix their reimbursements.

Frankly, I think it would all be easier and more appropriate if all vaccines were VFC. That will never happen, though, as long as the pharms can make good money.

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