I Hate Immunizations

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OK, now that I caught your attention, I need to explain (before some of the wacky folks who visit Flea start thinking I am in their camp). First off, aside from germ theory, sterile technique, and public sanitation, I think immunizations have saved more lives and improved the quality of more people\’s lives than nearly any other scientific discovery. Second off, I do not think there is any merit to the whole thimerosal/MMR/autism "debate." I think vaccines are safe and should be used whenever possible.

So why say I hate immunizations? It is the business side of being a doctor that hates them, not the medical side. Immunizations:

• Are the largest line-item on our budget apart from staff salaries.
• Have incredibly small margins of profit, so any rejection, failure to pay by either patient or insurance company can turn our small profit into a loss.
• Are constantly changing, so it is never sure which immunizations are covered by whom, making it hard to know if we should bill the patient up-front or bill insurance.

Let me give a few illustrations.

Influenza Vaccine

It used to be that the influenza vaccine was something that we could not get our patients to take. "It just gives me the flu" was the common response when we tried to get patients get them. No matter what the evidence showed, patients just did not want to get that vaccine.

Then something strange happened. There were a few large flu epidemics and subsequent fear of a pandemic made people suddenly want to get the flu vaccine. Patients wanted flu shots, and our office ordered a large quantity of them for the flu season of 2005-2006.

Unfortunately, that was also the season when there was a manufacturing problem with the influenza vaccine and we suddenly could not get them. Now patients, instead of angrily refusing to get the vaccine, were furious that they could not get the vaccine. We actually had patients (who were not at high risk for influenza complications) scream at us because we would not give them a flu shot due to the fact that we were saving it for those who were at high risk.

This past year we again ordered a large quantity of vaccine, being assured that there was no manufacturing problem. We got our first 100 doses in September, but then were told it wouldn\’t be until the end of November that we would get our next installation (of the 600 we ordered). Again we had angry patients.

To make matters more frustrating was the fact that Wal-Mart, Walgreens, and other pharmacies had plenty of flu vaccine. Why would we have problems getting them delivered to us while these businesses have plenty? I never got a good answer for that, but I have my suspicions that it regards a word that begins with "dol" and ends in "lar." In any case, we canceled the remainder of our shipment because we did not want to get stuck with 500 doses and no patients to give them to. We would lose serious money from doing this – besides, we could just tell patients to get them at Wal-Mart.

The other problem we face is the use of influenza vaccines in children. The current recommendations are that children from age 6 months to 5 years of age be vaccinated. Yet, as Flea summarizes in his blog:

Shinga over at Breath Spa for Kids tells us about an analysis and comment article in BMJ on the efficacy and effectiveness of influenza vaccines.

It turns out that the inactive vaccines we fleas give to kids under 6 aren\’t all that effective. For patients 6-23 months old the vaccine is no better than placebo, according the Cochrane Database of Systematic Reviews.

Live vaccines perform better, but we can\’t give them to kids under 6 years of age.

The author of the BMJ piece, Tom Jefferson (presumably no relation to the founding father, but one never knows) concludes with not a small amount of disappointment that inactivated vaccines have little or no effect on the outcomes studied in the literature. In many cases, Jefferson notes, the methods used in these studies are poor.

At the end of the day, according to Jefferson, we need better study designs. In the meantime, we ought to ask ourselves why we make policy based on such crappy evidence?

Okay, I\’ll ask the question: Why do we make policy based on such crappy evidence?

So we have the live vaccine (the nasal spray) that works well but is not covered by many insurances (and runs around $50). You can only use that between ages 5 and 50 – those who are least vulnerable and hardest to access. Then you have the less effective killed vaccine (the flu shot) that is the only one you can give to the high-risk populations. The low-risk people don\’t want to pay the high price of the nasal spray (especially if insurance does not pay), so they use up the supply of the high-risk population.

Sigh.

I am not looking forward to flu season next year.

Adolescent Vaccines

"Some insurances don\’t pay for adolescent vaccines," my partner informed me yesterday. I wanted to give a girl the HPV Vaccine and the TDaP (The new vaccine for tetanus, diphtheria, and pertussis for teens and adults). We have to make these patients pay before getting the vaccine because we are not sure they will be covered by certain insurance companies. There have been several new vaccines for adolescents/pre-adolescents recently, including:

• Gardasil – the HPV vaccine. This is recommended by the AAP and CDC to be given to all girls starting at age 11. While there is a big controversy surrounding the vaccine, that is not what I want to address. The real problem for us is that it costs around $120 per dose, requires three doses, and is not covered by all insurances.
• Menactra – this is the meningiococcal vaccine. Meningiococcus is a bacteria that causes a devastating form of meningitis in teens and young adults (occasionally in younger children). It is on every doctor\’s "dread" list, as it very rapidly kills previously healthy young people. This new vaccine is quite effective to prevent this disease and is recommended at age 11. It is required for entrance to college, yet many insurance carriers do not pay for it.
• TDAP – This vaccine is the tetanus booster that also treats pertussis, the bacteria that causes whooping cough. Studies have shown that the rate of pertussis in adults has steadily increased over the past number of years and this new vaccine helps prevent that. Yet insurance still does not reliably cover this.

On cue, I got the following communication from the AMA as I was writing this:

The AMA and the American Academy of Pediatrics co-hosted a meeting of key stakeholder organizations last week to address many challenges for patients who need vaccinations and the doctors who provide care for them. One of the outcomes of the Immunization Congress is to establish several task forces to pursue solutions to a specific set of problems surrounding access to vaccination, medical practice costs, public health system shortfalls and how vaccines are financed. Participants included 140 government and public health officials, manufacturers, distributors, private payers, advocacy organizations, pharmacy groups, community immunization providers and medical societies. In related news, physicians who are experiencing problems with inappropriate insurance reimbursements for immunization administration and vaccinations are encouraged to file a compliance dispute under the multi-district litigation (MDL) settlements with six of the nation\'s largest health insurers. This process has proved effective in making vaccines more available to patients, particularly in North Carolina, where several outbreaks of meningococcal illness on college campuses created demand for a vaccine that had been prohibitively expensive for students.

Finally, the insurance reimbursement for these vaccines is often at or below the cost it is for us to buy the vaccine. We can (and do) make it up with "administration costs," but end up having to raise the price for an already expensive vaccine just to make a profit.

So to summarize:

1. Immunizations are wonderful things that save lives and should be used more, not less.
2. Doctors have to buy the vaccines at very expensive rates and may not be paid by the insurance company, forcing them to charge the patient up-front or risk losing any profit.
3. The large number of new vaccines has made this situation far more confusing for patients and physicians.
4. Insurance companies capriciously set rates that are often not reasonable. They often continue not to pay for vaccines that are either required (for college entrance, for example) or greatly advantageous for patients.
5. Flu season has become a yearly debacle for my and many other physicians\’ offices.

Rant completed.