Vaccine Costs Affect Pediatrician Stocking Decisions

Larry Hand

February 26, 2014

Pediatricians and family physicians in private practice often resort to multiple strategies to deal with uncertainties about whether the purchase and administration of childhood vaccines will be covered by insurers, according to an article published online February 24 in Pediatrics.

In fact, 10% of family physicians and pediatricians surveyed had seriously considered dropping administration of all childhood vaccines, report Sean T. O'Leary, MD, MPH, from Children's Outcomes Research, Children's Hospital of Colorado, Aurora, and colleagues.

According to an American Academy of Pediatrics report, new vaccines have helped drive up the cost of childhood vaccines from being a minor overhead consideration in the 1980s to one of the top expenses now. Total costs of vaccines for a child up to age 18 years have gone from ~$50 in the mid-1980s, to ~$600 in 2000, and to $2250 to $2500 in 2012, according to the Centers for Disease Control and Prevention (CDC).

Therefore, the Colorado researchers collaborated with CDC researchers to develop a survey that included questions about physicians' experiences with purchasing vaccines and insurance payments, satisfaction with those payments, and strategies used when a new vaccine becomes available but insurance coverage is uncertain. They surveyed a national sample of pediatricians and family physicians between April and September 2011.

Of the physicians to whom the survey was sent, 69% (190/277) of the pediatricians and 70% (181/260) of the family physicians responded.

Their level of dissatisfaction varied significantly by payer type for vaccine administration. The physicians were least satisfied with Medicaid (63%) and were almost as dissatisfied with the Children's Health Insurance Program (56%). Managed care organizations fell in the middle, at 48% dissatisfied; preferred provider organizations came in at 38%; and fee for service payers came in at 37% (P < .001).

Many physicians also reported dissatisfaction for payment for vaccine purchase, but the difference between insurance types did not reach statistical significance (52% - 41%; P = .11).

Survival Strategies

Almost all (95%) of the physicians reported using at least 1 strategy to handle payment uncertainty, and 67% reported using 3 or more strategies. Most often, physicians would advise parents that they might be billed if no insurance payment were issued. More than half (60%) of the physicians reported that some parents had deferred or refused a vaccine because of cost or lack of insurance coverage.

Moreover, 10% of the physicians reported that they had seriously considered no longer providing childhood vaccines to privately insured patients because of cost, the researchers write, and those physicians had higher scores of dissatisfaction in the survey. In addition, 10% of family physicians reported that they that did not provide childhood vaccines.

Pediatricians were more likely than family physicians to delay administration of vaccines until insurance payment was certain (P < .01). That, the researchers write, "represents an important missed opportunity." Three of the 4 newer vaccines in question (HPV, MCV4, Tdap, rotavirus) are for adolescents who may not visit healthcare providers as frequently as younger children. "For adolescents, a missed opportunity may represent the only opportunity," the researchers write.

The Affordable Care Act requires that nongrandfathered private insurance plans provide coverage with no copays for all vaccines recommended by the Advisory Committee on Immunization Practices within a year after the CDC adopts the ACIP recommendation, but payment levels are not specified.

The researchers call for contract benefit language changes to be flexible enough to cover and reimburse new vaccines recommended by ACIP as well as to allow for vaccine price changes within a contract period.

Good Will Is Not Good Policy

"Here's an easy lesson for health reformers and policy makers: you get what you pay for," Joseph F. Hagan Jr, MD, from the Department of Pediatrics, University of Vermont College of Medicine, Burlington, writes in an accompanying commentary.

The overall picture of childhood immunization has changed with "the arrival of many new vaccines, overblown concern about vaccine safety and liability, and the astounding cost of many new vaccines," Dr. Hagan writes.

Public health policy today relies on the kindness of nongovernmental primary care physicians to provide patients' access to immunizations, and although pediatricians and family physicians have an "abundance of kindness...there are also limits," he writes.

Studies such as this one help physicians make essential decisions on how to deliver preventive care, and the decision by private clinicians to administer vaccines "is not as automatic as the public health sector would hope." The effect of such decisions goes further than immunization rates into current health reform efforts, he notes.

He concludes, "A public health system based on good will is a system at risk. We may just wind up getting what we pay for, and if we don't pay adequately, US youth will likely get less and less of the preventive health benefits we strive to achieve through vaccination administration."

This research was funded by the Centers for Disease Control and Prevention, administered through the Rocky Mountain Prevention Research Center, University of Colorado Anschutz Medical Campus. The authors and Dr. Hagan have disclosed no relevant financial relationships.

Pediatrics. Published online February 24, 2014. Article full text, Editorial full text

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