The provision of comprehensive immunization programs for the US population is fraught with difficulties, particularly for the independent primary care/community physician.
The provision of comprehensive immunization programs for the US population is fraught with difficulties particularly for the independent primary care/community physician. Vaccination rates are far lower in the United States than in other developed countries; especially those with national health services. Commercial development of new vaccines has not been very profitable for pharmaceutical companies, on the whole.
At the 2014 AAP National Conference & Exhibition in San Diego, CA, Herschel R. Lessin, MD, with The Children’s Medical Group, PLLC, Poughkeepsie, NY, introduced himself to the audience, saying that he has spent 30 years in private practice. He was co-author of the AAP 2010 Policy Statement “Increasing Immunization Coverage Remains a Priority,” which addresses the need to maintain and improve access to immunization throughout the United States.
He said the objectives of the session were to review underlying problems in pediatric practice economics and the customary business approach of pediatricians and to learn skills for finding practical solutions to critical business problems without compromising the delivery of quality pediatric healthcare.
Lessin came up with several quotes during his presentation to get his message across, including: “No margin, no mission,” “Business is not ‘dirty,’” and “Doing good and doing well are not mutually exclusive.”
He drew attention to various materials on immunization for pediatricians, such as AAP Policy Statements (including the aforementioned 2010 statement and “The Business Case for Pricing Vaccines”), “Vaccines: A Survival Guide for Pediatric Practices” and the “Immunization Training Guide & Procedure Manual.”
Vaccines are expensive to buy and the actual immunizations and the obligatory prior consultations are time-consuming to perform, especially for infants. Coding and reimbursement procedures are very complicated and can be somewhat arbitrary depending on the third party payor.
Reimbursement has improved somewhat in recent years with the introduction of coding for per-antigen administration. However, the adoption of combination vaccines has been slow because Medicaid and CHIP programs continue pay on a per-injection basis. Also these programs limit injections to three per visit which discourages the adoption of otherwise cost-effective multiple immunizations. In contrast, he opined that the CDC price list for the private sector is quite realistic in relation to actual costs.
Lessin said that a business case can be made for taking advantage of group purchasing organizations (GPOs) or similar associations. Pediatricians may also be able to benefit from Universal Purchase policies whereby the states or territories purchase all recommended vaccines for all children, whether or not they are fully-insured.
Regarding Medicaid-Medicare Parity, which requires physicians to comply with a unique attestation process to be eligible for the enhanced payment in the Medicaid program, Lessin encouraged pediatricians to lobby their legislators and to support their local chapter of the Pediatric Council.
Although there are many new administration codes, Lessin reminded the audience that some of the old ones have not been deleted and are still being used by Medicare, by law. Coding errors by the practice expose the individual practitioner to the risk of prosecution but it seems that insurance companies have more freedom to interpret the codes to their financial benefit.
He also stressed how important it is for practices to bill for EVERY single vaccine administered. Failure to bill for a single immunization can eliminate the cumulative profit from dozens of fully reimbursed vaccinations. The practitioner should check the immunization records. It is surprising how many vaccines are not accounted for properly. For instance, how many doses are not recorded, given away or wasted (eg, breakages)? The practice should ensure proper storage (refrigeration) and adequate insurance. For example, in the event of a power loss, what is covered?
Anti-vaccination enthusiasts are not worth bothering with, in Lessin’s opinion. He said you can try to persuade the fence-sitters. But pediatricians should beware; some parents back off at the last minute when the vaccine is already prepared for injection and cannot be returned to storage. If parents don’t want to accept the full range of recommended immunizations, you can be sure they will sue the pediatrician if their child gets meningitis. Lessin said he doesn’t treat kids who have not been fully immunized by 2 years.
Regarding adult vaccination, there are issues with liability, documentation, and payments. Lessin said, “I don’t mess with adult insurance.”
During question-and-answer time, there was discussion about counseling and/or vaccine administration by a “qualified health professional” and the definition. Someone in the audience insisted that the regulations are clear that this has to be either a Nurse Practitioner or a Physician’s Assistant.