Kathy Chebib, BS, MT

	With value-based care now a reality, here are some tips to keep your immunization program on track to benefit patients and your practice.

	
	A weekly inventory count can keep the appropriate amount of vaccine in your refrigerator. This count should take 10 minutes or less. A simple grid on a clipboard is all that is needed.

Top 5 tips to improve your practice's vaccine process

	
	The employee designated to place orders should use the inventory sheet to place weekly orders. That person can use a simple spreadsheet to calculate orders, based on historical usage. Orders should be placed online to capture any available online order discounts. Orders are transcribed to an “order received” sheet on the front of the refrigerator, where staff members can log shipments from the manufacturer.

	
	Vaccine administration varies among practices. Patients are screened for contraindications and precautions found on the package insert for each vaccine. After the vaccine information statement is given to the parent, and the physician explains the vaccines to be administered, the physician may administer the vaccine or delegate the task to medical assistants or appropriate staff members. You can subscribe to the CDC service that will notify you automatically when there are vaccine updates important to your practice.

	
	In addition to the vaccine itself, practices bill for the administration code. Administration codes are based on physician review of the vaccine with the parent/patient, number of antigens and the patient’s age. Coding resources are available through most manufacturers. They also maintain departments that are responsible for interacting with insurance companies and can intercede on behalf of a practice regarding reimbursement problems.        

How to improve your practice's vaccine procurement process 

	When ordering directly from the manufacturer under a physician buying group contract, you should be eligible for 90-day payment terms. This means you should be able to administer the vaccine, bill the payer, and receive reimbursement before paying your vaccine invoice. Credit card payments are accepted, extending the actual payment another month.

	
	Part of the value-based care initiative is based on successful vaccination numbers. If you have an EHR system that can perform a recall function, use it. You can also book all doses for vaccine series for older children/adolescents at one time to insure series completion for HPV and meningococcal vaccines. National statistics show a 40% or less completion rate for these adolescent vaccines, and series completion is receiving attention and resources to ensure improvement.

	
	The success of your program depends on the quality and regularity of your review. At least twice a year, and preferably quarterly, you should conduct a formal review, comparing vaccine cost and vaccine overhead to the reimbursement provided. Perform this exercise with your top 10 contracted insurers. This allows you to act on inappropriate reimbursement. There are pediatric EHR systems, such as PCC, that can provide reporting assistance to keep your vaccine program optimal.

	Participating in the vaccination process for your patients will provide you with necessary quality metrics and revenue for your practice. As we continue to focus on the best healthcare and outcomes for our patients, the role of excellent vaccination processes cannot be ignored.

	The following statistics give a dollar value and a health value to immunization efforts;

	• Among 78.6 million children born during 1994–2013, routine childhood immunization was estimated to prevent 322 million illnesses (averaging 4.1 illnesses per child) and 21 million hospitalizations (0.27 per child) over the course of their lifetimes and avert 732,000 premature deaths from vaccine-preventable illnesses, according to the CDC.

	• Each year, approximately 42,000 deaths of children and 50,000 adult deaths in the United States 

indicates that every dollar spent on pediatric vaccines 

in direct and indirect costs each year as a result of the pediatric vaccination program.

, has been a practicing pediatrician for SF Bay Pediatrics in San Francisco for 40 years. He completed an immunology fellowship from the University of California, San Francisco and is a clinical professor of pediatrics at UCSF and a consultant in infectious disease. He has led the Pediatric Federation community from its inception.

, a trained medical technologist, has been a pediatric business manager and practice administrator for more than 30 years. She works for Golden Gate Pediatrics in San Francisco, and helps with the cooperative endeavors of Pediatric Federation. 

Articles

A practice’s immunization program requires constant attention and oversight. Here are seven best practices to consider.

7 strategies to maintain a successful vaccine program

	For those practices that do not routinely offer vaccinations, or are struggling to maintain a successful program, we would like to offer a basic outline of the process. Adhering to this process should deliver healthier, vaccinated patients and increased revenue, and will represent an important step towards meeting the preventative health measures in value-based care.

How to improve your practice's vaccine procurement process

Review a comprehensive immunization training guide.


	The Centers for Disease Control and Prevention, American Academy of Pediatrics (AAP) and many state health departments offer formal training guides to assist with setting up a successful and complete vaccination program for your practice. (See a list of recommended resources below.)

Appoint an office vaccine coordinator with specific duties.


	As you practice medicine, there will be appropriate areas requiring routine oversight.


	There are strict requirements regarding the refrigeration, temperature monitoring and systems of storage to ensure the integrity of the vaccine. There are options with pros and cons (visit 

 for some good insight on this topic). Review your general liability insurance with your broker to see if you need a rider to cover the vaccine you store. Practices providing vaccines for children to low-income patients should review those requirements from your state public health department.


	There are a finite number of vaccines available. You should not pay any more than necessary for the schedule you prefer. Take the time to crunch your numbers, and understand the benefits and drawbacks of the various purchasing options. Ordering your vaccine from a distributor generally will result in the highest cost. Ordering direct from the manufacturer is a less expensive option. You may also order directly from the manufacturer under several contracted options:

	• Internal vaccine contracts; (Some manufacturers have a contract that they offer to single offices that meet their purchasing requirements. PediaFed pricing is better than this internal contract because we return our admin fees in the form of rebate)

	• Large GPO contracts, usually found in hospitals (these are not vaccine directed and do not have the level of vaccine discounts found in other options, according to the manufacturers); or

	• Physician buying groups (these usually receive the highest level of discount available)

	Purchasing groups that return unspent administrative fees can significantly lower cost. You should be able to calculate the rebate amount your office will receive by reviewing the buying group pricing grids. Careful attention to this part of the process should provide a cushion towards fluctuating insurance reimbursement rates and give your practice the lowest vaccine cost available.


	This is a critical part of the process. The revenue from providing vaccinations should contribute appropriately towards your practice overhead. For help with this process, we recommend the "Business Case for Pricing Vaccine" guide from the AAP. This reference states that most practices will have overhead costs from routine immunization of 17%-28% over the cost of the vaccine.

American Academy of Pediatrics (AAP) Immunization Training Guide:

 https://www.aap.org/en-us/Documents/immunizations_training_guide.pdf

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunization/Pages/quality-improvement.aspx

https://www.aap.org/en-us/Documents/immunizations_thebusinesscase.pdf

 http://www.cdc.gov/vaccines/events/niiw/ed-resources/partner-resources.html

American Academy of Family Physicians (AAFP) Vaccine Coding Guidance:

http://www.aafp.org/practice-management/payment/coding/admin.html

Vaccine Storage and Safety Guidelines (from pediatric practice consultant Chip Hart):

 http://chipsblog.pcc.com/vaccine-storage-and-safety-guest-blog-and-survey/

, a trained medical technologist, has been a pediatric business manager and practice administrator for more than 30 years. She works for Golden Gate Pediatrics in San Francisco, and helps with the cooperative endeavors of Pediatric Federation.

Keep patients-and your practice’s bottom line-healthy with these suggestions for a successful immunization program.

	During the early 1990s, our world of medical practice took a drastic turn. Managed care was introduced, and physicians found themselves in the position of having to accept insurance company contracts with significant discount rates. As a pediatric practice, running on a tight budget, it was difficult to imagine how we could function properly under these new financial constraints. Local pediatric practices met and discussed our common problems. Physicians, nurses and managers contributed their “best practice” solutions. From these initial meetings, a community developed, based on cooperative solutions for the common good.

	One significant problem practices shared was their inability, to qualify individually for the highest level of vaccine discounts, which were based on quantity. These discounts, extended only to exceptionally large practices, amounted to many dollars per dose. Vaccine purchase was a significant part of our budget at that time, and now for many pediatricians, vaccine cost is their largest expense, exceeding staff payroll.

	After negotiating with the vaccine manufacturers, our small community became the first group purchasing organization (GPO) for vaccines. Pediatric Federation LLC was born. Manufacturers recognized our organization as one customer, and we were able to extend the large practice discounts to all participating practices, no matter its individual size. In exchange for these significant discounts, we promised to purchase our vaccine from contracted manufacturers.

	Our organization now extends across the country, spread largely by word-of-mouth recommendations. Pediatric Federation follows a three-year bidding schedule, extending bid requests to all vaccine manufacturers. Our advisory board carefully reviews science, pipeline and financials. Bid information is submitted to all participating practices and we vote on which suppliers we use. We cooperate to achieve the greatest discounts, and unspent GPO administrative fees are returned to our participating practices, making for a significant, additional discount to members’ costs. This important benefit of our GPO distinguishes us from similar organizations.

	Medical practices once again face astonishing change as we move from fee-for-service to value-based care. Throughout the country, we see practices being acquired by foundations, hospitals and academic systems, as well as small practices consolidating into larger groups. These consolidations are driven in part by the need to gain the necessary size and resources to meet the value-based goals of lowering cost, while improving quality and outcomes, among which are improved immunization and vaccination rates.

	Physicians understand the importance of vaccination. Very few medical interventions have had such a positive impact on population health. We must, therefore, use every opportunity to help our patients understand the value of vaccinations, and to have those vaccines available when our patients are due for them. In recent years we have seen a growing emphasis on adult vaccination, with internal medicine, family practitioners, and OBGYNs becoming routine immunizers.

Learn from one practice’s innovative approach to successful vaccine management to improve patient care.

Author | Kathy Chebib, BS, MT

Articles

7 strategies to maintain a successful vaccine program

Top 5 tips to improve your practice's vaccine process

How to improve your practice's vaccine procurement process