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Despite community benefit, vaccines have taken a toll on physicians
As the costs of vaccines continue to rise, some physicians question whether they can continue to immunize their patients.
A few months ago I moderated a group round table in Atlanta that discussed the effect on practitioners of the cost of vaccines.
It is not news that we have newly recommended vaccines that generally have been logarithmically costlier than the older ones. How will practitioners continue to afford to vaccinate? The question obviously does not have a simple or a single answer. Large practice groups will have special approaches not applicable to others, and the problems may need to be addressed differently in various locations.
One of the things that became apparent during our discussion (see related article) is that physicians are spending more time explaining the costs of vaccines to parents who pay out of pocket and negotiating with third-party payers, vaccine manufacturers and other stakeholders, when that time should rightfully be devoted to patient care. When I mentioned that this is not what we were trained to do, one of the participants said that he discusses these issues with residents. Is this really what physician training programs should be doing? Is it any wonder that primary care has lost some of its appeal? It requires as much effort to negotiate the cost of a surgical procedure that costs thousands of dollars as it does the cost of a vaccine. In addition, physicians must deal with non-physician clerical representatives of multiple third-party payers, either directly or through hired intermediaries.
Protecting the community
One of the points made at the meeting was that being immunized serves not only the vaccinees but also the entire community. This has been recognized by the more generous Medicare reimbursement for immunization of the elderly with influenza vaccine. All of the vaccines given, with the exception of tetanus, are against communicable infectious diseases. By immunizing the vaccinees, the community is benefiting.
We have done such a fabulous job of immunizing our children that many of us have never seen the diseases these vaccines prevent.
Vaccination has been the most cost-effective public health measure. This laudable accomplishment is taken for granted. In the United Kingdom, the immunization rate for measles-mumps-rubella had fallen to 70% in some areas as a result of the Wakefield fiasco. At that time the number of measles cases in their country exceeded ours by several fold, despite our much larger population. One of my frustrated English colleagues commented that no one would do anything until someone died – and someone did.
It is inconceivable that physicians might stop immunizing. But, how can we continue? In a recent study before the introduction of the latest batch of new and expensive vaccines, it was reported reimbursement had fallen and that for four pediatric practices surveyed, cost was 22% greater than reimbursement (Pediatrics. 2004;113:1582).
The outlay for vaccines at the present time can run into the tens of thousands of dollars. Reimbursement from third-party payers may lag months behind your investment and, in some cases, might not cover the cost of the vaccines. Administration fees vary widely and fail to take into consideration the time spent in explaining vaccination, storage of vaccines, record keeping and other time consuming functions. Freezer failure is a fear that has driven some to put in alarm systems and generators. I have been told that insurance against failure may be difficult to buy in some areas. Consumer driven health plans may result in some parents choosing not to have their children immunized because of out-of-pocket costs.
Solutions
What are the solutions? There are two that have been used in other countries that are not options in the United States at this time. One is universal health insurance and the second is dedicated vaccine workers, which take children from their “medical home.”
National legislation to regulate vaccine issues will be fought by the powerful opponents of mandated health care coverage and controlling drug costs. During our discussions, Walt Orenstein, MD, suggested that the Centers for Medicare and Medicaid be asked to draft standards for reimbursement, as having a national recommendation would provide a benchmark. In the states, various mechanisms have been used to attempt to address reimbursement. These efforts would be enhanced and encouraged by national guidelines. The utilization of guidelines would vary by state, which probably would reflect the difference in immunization rates between states.
We have an urgent problem that is complex and will require intensive efforts to solve. I do not think that we can set this aside. Failure to resolve these issues might result in the reappearance of diseases that are now rare or nonexistent. A recent meeting reported in the March 2006 Clinical Infectious Diseases addressed the concern about vaccine shortages. There were repeated references to financial incentives required for vaccine manufacturers to stimulate vaccine manufacture in this county. It is time that the concerns of practitioners are addressed in a similar context.
In the October commentary entitled “Forbidden Fruit,” I misquoted the abstract at the Infectious Diseases Society of America Annual Meeting, written by Noel and colleagues, which is on page 241, LB-27. It does not change the conclusions or the message. Dr. Noel‘s letter calling this to our attention was published as a clarification in the January issue of Infectious Diseases in Children.
There was a 2.2% incidence of musculoskeletal complaints at 60 days in the levofloxacin recipients compared with 0.9% (p.0.27) in the comparator group, mostly due to arthralgia, although the difference for this side effect alone was not significant at 60 days (P=0.063). There was no difference at 30 days or more importantly at one year in any of the groups including, most importantly, growth.