Combination Vaccines May Be a Financial Burden to Physicians

Although the use of combination vaccines is gaining popularity in pediatrics, a recent survey reported in the Archives of Pediatrics & Adolescent Medicine shows physicians may face financial trouble when incorporating these vaccines into practice [2010;164(12):1138-1144].

The physicians surveyed reported increasing use of the combination vaccines due to the reduction in the number of injection sites needed for routine childhood immunizations and the improvement of timeliness in receiving vaccines. Typically, under fee-for-service contracts, physicians receive a separate fee for each injection administration to cover vaccine preparation, injection, and documentation; when combination vaccines replace the usual ≥2 injections with a single injection, physicians may lose income from administration fees. The authors did a national survey of pediatricians with a mailed, self-administered questionnaire containing 17 closed-ended questions. The study focused on the use of 1 of 2 infant combination vaccines: the diphtheria and tetanus toxoids and acellular pertussis, hepatitis B virus, and inactivated poliovirus (DTaP-HepB-IPV) vaccine and the DTaP, IPV, and Haemophilus influenzae type b (DTaPIPV/Hib) vaccine.

Of the 629 pediatricians who responded, a 67% response rate, 1 in 5 reported that inadequate reimbursement prevented their using ≥1 combination vaccines. Seventy percent of the respondents reported using the DTaP-HepB-IPV vaccine, while 29% were using the DTaP-IPV/Hib vaccine. Another 30% of physicians planned to use the DTaP-IPV/Hib vaccine in the next 12 months. Ninety-nine percent of respondents believed combination vaccines to be safe and effective. Of the respondents who reported inadequate reimbursement, 23% reported inadequate reimbursement for purchase and 20% reported inadequate reimbursement for administration as preventing their use of ≥1 combination vaccines. Ninety-seven percent of respondents believed that the financial stability of their practice depends on revenue from vaccines, although approximately half of the physicians agreed that practices should continue to offer combination vaccines despite the financial burden. In a secondary model of the survey results, the authors added 2 additional predictor variables: (1) whether the respondent reported that reimbursement for the cost of the purchase of combination vaccines was adequate, and (2) whether reimbursement for theadministration of combination vaccines was adequate. When adequate reimbursement for vaccine administration alone was added to the primary model, it was significantly associated with combination vaccine use (odds ratio 3.2; 95% confidence interval, 1.9-5.5).

The practice size was also a determinant of the adoption of combination vaccines, with larger practices and practices with the highest proportion of patients with public insurance associated with the increasing use of these vaccines. Results from previous studies support these findings surrounding the financial barriers to providing combination vaccines, with another study finding that 58% of its respondents were not adequately reimbursed for the purchase of vaccines and 51% reporting inadequate reimbursement for the administration of vaccines. The authors of this study say the findings suggest that when practices are provided with vaccines free of charge, the remaining potential barriers to combination vaccine use may be eliminated. A limitation of this study is that the authors were not able to quantify the adequacy of reimbursement, as the study was self-reported. Some pediatricians may attribute inadequate reimbursement to losing revenue, whereas others might signify only a decreased profit margin. A further limitation is that the study was conducted during a national shortage of Hib vaccine, during August 2008; therefore, it most likely increased the use of DTaP-IPV/Hib accines, altering reported use. The authors recommend providing vaccines free of charge through state and federal programs to reduce the financial burden placed on pediatric practices. There needs to be a collaboration between physician groups and health insurers to make combination vaccines more easily available, according to the study.