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Wednesday Dec 14, 2016

Making Our Point on Immunizations With Vaccine Manufacturers

Year after year, the United States spends more money -- far more -- on health care than any other country in the world(www.commonwealthfund.org). To date, the results fail to reflect that high level of investment.

Take, for example, a 2015 report from the World Health Organization(gamapserver.who.int) that tracked first-dose measles immunization coverage for 1-year-olds. The United States ranked 114th.

Since 2010, insurance plans have been required to cover immunizations recommended by the CDC as preventive services. During the same period, the percentage of uninsured Americans dropped to historic lows. Despite that alignment of recommendations and increased coverage, the CDC reported recently that childhood immunization rates remain below Healthy People 2020 targets(www.cdc.gov) for diphtheria, tetanus and acellular pertussis (DTap); Haemophilus influenzae type b (Hib); hepatitis A; hepatitis B (birth dose); and rotavirus vaccines.

Adult immunization rates are even worse. Despite the fact that annual influenza vaccination is recommended for all people ages 6 months and older who do not have contraindications, only 43 percent of U.S. adults received the vaccine in 2014(www.cdc.gov). The rate of coverage is only slightly higher for pregnant women(www.cdc.gov) despite their heightened risk for complications.

So what do we do about it?

The AAFP recently held an immunization summit at its headquarters in Leawood, Kan., speaking with representatives from seven vaccine manufacturers about immunization rates, barriers to increasing rates and other related issues.

AAFP leaders and staff heard from the manufacturers, and we, in turn, talked about the work of the Academy and family medicine overall in this area. Several family physicians and their care teams teleconferenced in to share their experiences increasing vaccination rates in their practices. 

I assured the manufacturers that our members understand the vital importance of vaccines. I wanted them to understand the barriers we face and how immunizations fit into our world of prevention and chronic disease. I walked them through a typical day in the life of a family physician, which I based on a recent day in my clinic that illustrated the diversity and complexity of what family physicians do and the time constraints we face.

On that morning, I saw 11 patients ranging in age from 3 to 70. I also handled prior authorizations and refills and returned phone calls. Of the 11 patients, six were new and five had chronic conditions.

For example, I saw a 60-year-old woman with diabetes, obesity and nonalcoholic fatty liver disease. She was initially resistant but eventually agreed to receive flu and pneumococcal vaccines. That's a lot to cover in a 15-minute visit.

The manufacturers now understand that we often deal with multiple diagnoses with each patient and an assortment of payers who require that we report on different quality metrics. Support from industry in reducing administrative burden, I said, could give us more time to think about other things -- such as vaccination rates.

Similarly, I had a 66-year-old man with a hernia, osteoarthritis and lipid issues. He needed labs, and I referred him to a subspecialist for a basal cell carcinoma near his eye. He received flu and pneumococcal vaccines in my office, but I sent him to the pharmacy next door for the herpes zoster vaccine. This latter step confused the patient, and he's probably not alone.

I explained to the manufacturers that many primary care practices don't handle the frozen shingles vaccine because it presents logistical issues and time constraints for both patients and practices, in addition to the fact that it's covered by Medicare Part D rather than Part B. 

According to the CDC, only 28 percent of Americans 60 and older have received that particular vaccine as recommended.

We again expressed our frustrations related to the flu vaccine, particularly the fact that family medicine practices often receive shipments after bigger retail customers. This leads to patients seeking the vaccine elsewhere, fragments care and leaves family physicians with vaccine that is no longer needed. One family physician in our meeting said that in one recent year, he was stuck with $5,000 worth of flu vaccine because by the time he received his order, his patients already had been vaccinated at retail pharmacies, grocery stores, etc.

We discussed the lack of integration of electronic health records, the inability of state vaccine registries to communicate across state lines and the need for a national vaccine registry, as well as manufacturer support for such an endeavor. Other topics included vaccine refusal, reaching the uninsured and the complexity of ever-changing vaccine schedules.

This will be an ongoing conversation with manufacturers, and these hurdles will not be resolved overnight. The industry's understanding of our perspective, our challenges and our mutual opportunities was certainly improved by this meeting, however, and that's an important first step.

Wanda Filer, M.D., M.B.A., is Board chair of the AAFP.

Posted at 11:12AM Dec 14, 2016 by Wanda Filer, M.D.

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