Doctors Balk At Vaccinating Pending Plan Reimbursement Increases

Cheryl Clark, June 29, 2010

With a state-declared epidemic of whooping cough threatening to set a 50-year record of illness and death in the state, some California physicians are refusing to administer the vaccine to adults or children, saying that health plans aren't reimbursing them anywhere near what it costs them to buy it.

"I'm a solo practitioner, and there's no way I can afford it," says Marsha McKay, DO, who treats patients in Twain Harte, a small town in the Sierra foothills southeast of Sacramento. To buy each dose costs her $61.50 in batches of ten, but insurance plans only pay about $45. "And that doesn't count the cost of the special refrigerator I need to store it, or the price of syringes and the nurses' time."

She says she hates to do it, but she must send patients to the Tuolumne County Health Department or nearby rural health clinics, and she has no idea whether they actually go. She can't see newborns up to six months old anymore because she can't afford to vaccinate them, and the local health department will only take patients with no insurance.

According to the California Department of Public Health, the state has counted an excess of 1,500 illnesses so far this year, nearly eight times the number of cases for this period a year ago, and the numbers are expected to continue their climb. So, far there have been five confirmed deaths, and state officials expect that number to climb as well. Nationally, several other states such as Ohio are seeing early bumps in their cases.

Sending pediatric patients to retail pharmacies for vaccinations isn't an acceptable option, because spokesman Michael Sicilia says "Most pharmacies do not offer vaccine to children under 11 years of age, although a few gave H1N1 vaccine to children as young as eight. "None have given to younger age groups that we are aware of.

Sicilia added "provision of routine immunizations to the pediatric population is best delivered in the patient's medical home, if possible."

The California Academy of Family Physicians is trying to fight back with a bill now being debated in the Legislature. If approved, it would be illegal for health plans to reimburse physicians an amount for childhood or adolescent vaccinations in amounts less than the physician's actual cost of acquiring and administering the vaccine.

The proposed legislation adds that physicians or physician groups "shall not be required to assume financial risk for immunizations, regardless of whether those immunizations are part of the current contract."

CAFP spokesman Tom Riley says the problem is most acute with small practices in rural areas of the state. "The large practices are able to avail themselves to bulk purchasing or wholesale prices, but the smaller rural practices are just trying to hold it all together.

In a statement last week, CAFP said many vaccines aren't appropriately reimbursed by health plans. "At a time when pertussis, a vaccine-preventable disease, has just been declared epidemic in California by the state, and when H1N1 shows us the vey real possibility of pandemics, we must have a strong vaccine-delivery system in physician offices, where most children and adults expect to be able to get vaccines," CAFP said.

"Many doctors report that as a consequence of insufficient payment, they are referring patients out to the public sector (e.g. community clinics) for vaccines, which pushes costs back onto the state and decreases local access to vaccines, which is dangerous to public health."

CAFP points to an survey published in last year's edition of the journal Pediatrics, which found the following:


  • One in five doctors are considering no longer providing all recommended vaccines to privately insured children
  • Nearly one-fourth of physician practices either discontinued a relationship with a payer because of a level of payment or stopped administering vaccines to patients in a certain plan because of reimbursement did not cover purchase and administration.
  • Average administrative fee reimbursement was only $16.39 to $26.55 for the first dose, and lower for second doses.


McKay says she worries what might happen if patients who get vaccinated have an adverse reaction. "For the adult immunizations for pertussis, I have to send patients to the Safeway pharmacy. But I don't know if they ever get the vaccine, and if they have an adverse reaction, I will have no idea, though occasionally, I will get a note back saying 'we gave this to your patient.' "

McKay says when she complained to Blue Cross "they told me to attach the invoice of what I paid for the vaccine to each claim and they 'would consider' paying enough to cover my costs. I cannot put out thousands of dollars in buying vaccine to get stuck with the loss if Blue Cross does not come through."

She has also asked patients to pay cash up front, and then get reimbursed from their insurance companies. But, she says, "No one has taken me up on that yet. They can hardly afford their premiums and their co-pays."

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