Costs May Cause Some Docs to Quit Offering Vaccines

The high costs of childhood vaccinations have led a sizable percentage of doctors to strongly consider whether to stop providing the vaccines to privately insured patients, says a newly released study. And some family physicians already have stopped, AAFP News Now has discovered.

According to the study, which was published last month in the journal Pediatrics, 5 percent of pediatricians and 21 percent of family physicians polled reported that they had seriously considered not offering the recommended childhood vaccines.

FP Kathy Saradarian, M.D., of Branchville, N.J., told AAFP News Now that she has limited her practice to patients 5 years of age and older largely because of these very cost concerns. She said she no longer stocks many of the most commonly administered pediatric vaccines -- such as the diphtheria, tetanus, acellular pertussis and polio vaccine and the measles, mumps and rubella, or MMR, vaccine -- because she simply can't afford to keep offering them.

"I was probably breaking even on vaccines," she said. "I know that in my previous practice, we found there were vaccines we were getting paid less than cost, and when we appealed, we were told that the administration fee made up the difference.

"Part of the problem is that you have to buy, say, 10 MMRs," Saradarian explained, "and if I don't have 10 12- to 15-month-olds or 4- to 6-year-olds in my practice, I won't use them before expiration."

G. Andrew McIntosh, M.D., a family physician practicing in Uniontown, Ohio, said patients can receive MMR at a local health clinic for $12, but the vaccine costs him $117 per dose.

"We want to order vaccines," he said, "but with uncertain reimbursements and end-of-the-year expenses, I doubt we will provide immunizations any time soon."

Ten children have left his practice since he stopped giving vaccines last fall, said McIntosh, and he fears the parents and family members of those children also will begin seeking care elsewhere.

"Offering pediatric care in a family setting is what keeps me going in my practice," he said. "A well-child check erases the pain of seeing the patient with 15 meds and twice as many complaints. Young patients are healthier, and more importantly, interested in preventive health care. I feel like I can actually make progress with more proactive patients. Children provide young, motivated patients that make the job more fun.

"We love our old people, but like most other family docs, we crave variety and multiple challenges. A geriatric-only practice, for me, would be much less satisfying and hasten my exodus from family medicine."

Pediatrician Gary Freed, M.D., M.P.H., a co-author of the Pediatrics study, said that if family physicians stop giving childhood vaccines it could be problematic, especially in rural areas, where there are fewer pediatricians and other health care professionals.

Freed, the Percy and Mary Murphy Professor of Pediatrics, director of the Division of General Pediatrics and director of the Child Health Evaluation and Research Unit at the University of Michigan, Ann Arbor, said there once were 15 states with so-called universal purchase programs. However, he added, there now are only six such programs, in which states buy vaccines and distribute them to immunization providers.

"As vaccines have become more expensive, fewer states are able to afford this," Freed said. "No one is pushing this now due to the cost."

McIntosh contends that more of these types of programs are needed, with states taking advantage of their considerable buying power.

"I'm not a socialized medicine guy," he said, "but for immunizations, there needs to be a statewide program where we're given vaccines to administer. It would be a good investment. Some states have immunization rates at 60 percent or 70 percent. That's totally unacceptable in a Westernized country."

Freed and his co-authors, whose vaccine study was funded by the CDC, note in their report that the cost of purchasing all doses of the recommended childhood vaccines jumped from $600 per child in 2000 to $1,500 in 2008. That boost reflects increases in the total number of doses recommended for existing vaccines, along with the addition of new recommendations for administration of recently approved vaccines, such as the heptavalent pneumococcal vaccine.

Nearly half of study respondents said their practices had delayed the purchase of a new vaccine because of costs, and 53 percent said their practices had experienced a decrease in profit margin from pediatric immunizations in the past three years. Also, 65 percent said they would not give a vaccine if the reimbursement amount was less than the purchase price.

In a related study published in the same issue of Pediatrics, the authors said that 24 percent of practices polled had discontinued a relationship with an insurance company or stopped administering vaccines to patients in certain health plans because of low reimbursement levels.

A handful of third-party payers, including CIGNA HealthCare, Humana Inc. and WellPoint Inc., have improved their reimbursement rates in recent years, McIntosh said, but more needs to be done to allow doctors to cover the full costs associated with providing immunizations, including elements such as staff time.

"Some of the reimbursements need to go up 50 percent," he said. "We should get reimbursement against costs, plus 20 percent. That would be fair. We would break even at that point."

One way some FPs have found to cope with the high costs of handling immunizations is to join a group buying program.

Brian Bachelder, M.D., of Mount Gilead, Ohio, said the Ohio AFP joined Atlantic Health Partners last year, decreasing his vaccine costs by an average of 10 percent. Ohio is one of 17 AAFP constituent chapters in the Atlantic Health Partners program.

"That's been a very nice change for us," he said. "It's one of the things that has allowed us to continue doing immunizations."

As a solo practitioner in a small town, Bachelder admitted it's been difficult to keep dealing with vaccine costs.

"We're investing thousands of dollars on something we make pennies back on," he said. "No businessman in his right mind would make that investment, but that's what is expected of us."

Even so, Bachelder said he is committed to offering the vaccines because they are a critical component of patient care.

"We've always felt it was the right thing to do," he said. "All the other doctors in our area have stopped giving immunizations. They send everyone to the health department. That's a problem. The economic environment is very bad in Ohio -- like it is everywhere -- right now. The health department is cutting back on services. They're still providing the basic immunizations, but I wonder if that's going to be true down the road."

Bachelder said he feared that not offering the vaccines might hurt his practice in the long run.

"If you cut back on the low end of services, you're going to lose patients," he said. "If they start out with another physician, what's their reason for transferring to you?"

Moreover, said Bachelder, offering the vaccines is consistent with the concept of a patient-centered medical home.

"The more we divide these things up, the more we have problems with that patient-centered atmosphere," he said.

Bachelder said that in addition to joining a buying program, his practice tries to manage expenses by keeping a list of vaccine costs and updating it quarterly. He said that if reimbursement levels fall too low, his office contacts the insurance companies.

"We have some leverage as one of the few practices in our area offering vaccines," he said. "You have to monitor your costs."