Making the Shots Even Longer

I know that I was distracted through most of July working on my peer review materials. However, that didn’t mean I wasn’t paying attention. So, I when last week I was listening to All Things Considered on NPR, a story on vaccines caught my attention.

The story, reported by Kelly Weiss, was about physicians, both pediatricians and family practitioners, who were struggling with whether and when to provide some of those vaccines that we feel are a part of childhood. While we’ve heard a lot in the past few years about parents (and a rare few doctors) having anxieties about ingredients in vaccines, and about associations of vaccines with long term consequences such as autism, that wasn’t the problem. Instead, the problem was expenses related to the vaccines themselves. The physician interviewed spoke of paying for vaccines almost twice what insurance companies would reimburse. As a result, she spoke of delaying vaccines for children, or, for some children, of foregoing vaccines entirely. Even as she was being interviewed for the story, she was conscious of the outbreak of whooping cough not far from her in the Los Angeles area, and of the risks faced by any patients she hadn’t vaccinated.

In her story, Weiss interviewed Dr. Gary Freed, and cited his work. He and colleagues published the article, “Primary Care Physician Perspectives on Reimbursement for Childhood Immunizations,” available on line in the journal Pediatrics (in its first publication here, and in a “supplemented” version here – but, I can’t spot the difference). They surveyed 1280 pediatricians and family practitioners, and had a 65% response rate. They asked questions about the purchasing of certain vaccines for children, about reimbursement for providing them, and about whether the physicians had delayed or had stopped providing the vaccines, and whether they had considered no longer providing any vaccines. They also asked whether the respondents were directly involved with decisions about purchasing and distributing vaccines so as to distinguish the responses of those “directly” involved from those “indirectly” involved.

The responses were very interesting. Almost half (49%) said they had delayed purchasing a new vaccine for financial reasons. Those “directly involved” were more likely to report this than those “indirectly involved.” 58% “disagreed” or “strongly disagreed” that reimbursement was adequate for the purchase of vaccines, and 51% “disagreed” or “strongly disagreed” that reimbursement was adequate for the administration of vaccines. 65% “agreed” or “strongly agreed” that they would not provide a vaccine if the cost were more than the reimbursement. When asked whether respondents or their practices had considered no longer providing vaccines to privately insured patients, 66% responded “never;” which means, of course, that 34% had at least considered it.

While the researchers did ask about discontinuing vaccines, they felt all of the results spoke of issues in adequately protecting their patients and the public. They wrote:

Discontinuation of immunization services should not be the only end point of concern. Almost half of the physicians in this study had delayed purchase of a recommended vaccine due only to financial concerns. Al- though the length of the delay was not specified, this implies that at least some children either did not receive recommended vaccines, and therefore remained at risk for vaccine preventable diseases, or that they may have been referred to the public health system for vaccination.

Now, before we get all high and mighty about greedy physicians only in it for the money, there are several things we need to remember. First and foremost, in our market-oriented health care system, most physicians are really small-business persons. That’s what a private practice office is, really. Yes, the physician wants to make enough money for themselves and their families (and fewer and fewer of them are getting rich in their practice) and to be reimbursed adequately for their training and levels of responsibility. However, they also have employees to pay and provide benefits for. They have to pay rent on space, and to pay the utilities. They have to provide equipment and supplies, and to replace them as they’re used up (and while a doctor may or may not want to be “not for profit,” you know the companies they by from are as profit-centered as one can imagine). They also have other expenses, such as their malpractice insurance and, for many of them, student loans.

Remember, too, that those expenses can be expected to rise gradually from year to year. We expect a certain amount of “growth” in our economy, and that “growth” translates into higher prices. And even the “not for profit” have to keep up, or cease to offer services. As many have noted before, “No margin, no mission.”

There is, of course, an important moral issue. As I have discussed, all health is public. That is, each of us is affected as an individual by the health of others and by the health of the community as a whole. The current outbreak of whooping cough is a good example. Whooping cough or pertussis is a serious disease, dangerous both for children and adults. We have thought it controlled, but that was precisely because almost every child has been vaccinated. The small number of children who didn't get vaccinated because they couldn't medically were still somewhat protected by the "group immunity;" that is, if almost everybody was immune, there would be almost noone from whom to catch it.

But that has changed in the past decade. Sure, it's still the case that the great majority of kids get their vaccinations. However, the number of kids who don't has been creeping up. Some of that is anxious and misinformed parents. Some of that is our current recession, with people losing employer-based health insurance and/or having less money for health care (or anything else). Some of that is new immigrants, both documented and undocumented, who don't know or are afraid to use the resources available.

And some, it appears, may be the net costs (vaccine cost minus reimbursement by insurance and/or patient) to private practice physicians. None of the other three issues are new, although they all appear to have grown recently. This last feels new, or relatively new, to me. We have enough trouble addressing the first three problems, and I don't think we need a new one.

There are some states that address this differently. In “universal purchase” states, certain vaccines are purchased by the state at a price negotiated by the Centers for Disease Control, and then distributed to both public and private providers. They then provide them to patients at little or no cost. Providers can also purchase vaccines from manufacturers if they would prefer, and charge for them as seems appropriate. (Note that Freed et al did not include in their survey pool physicians in “universal purchase” states.)

There are also issues simply about how much vaccines cost. Unlike medications for chronic disease and health maintenance, vaccines aren’t that profitable. After all, if they work, each dose is given once. A drug for cholesterol or for blood pressure is taken every day, perhaps for a lifetime. So, for the pharmaceutical company those drugs for ongoing use are a lot more profitable. Since pharmaceutical companies are certainly for-profit, they tend to focus their research and development on the drugs that will make the most money. That’s not to say that they’re not interested in the public good. However, their profit, and not the public good, is the measure of their value and success.

Perhaps it’s best to come back to what I said above: that this is simply another issue in providing childhood vaccines that protect our children – and, really, all of us. We need, really, to be addressing all of them. However, among the four I mentioned (and there is at least one other, that of adequate access to providers in general, which is most acute in our most urban and our most rural areas), this is the one we haven’t noticed. Like the others, we need to work on the problem; and like any other problem, we can’t work on it until we’ve noticed it’s there.