Who Gets Stuck?

Gary Bergman of Northern Virginia said his  practice
Gary Bergman of Northern Virginia said his practice "probably breaks even" providing vaccines, which he regards as a core mission of pediatrics. (By Katherine Frey -- The Washington Post)
By Sandra G. Boodman
Washington Post Staff Writer
Tuesday, May 1, 2007

When Merck launched a multimillion-dollar marketing campaign last year to promote Gardasil, its new vaccine to prevent cervical cancer, company officials probably did not anticipate that its signature phrase -- "one less" -- would apply not just to malignancies but also to physicians. Yet that slogan has come to symbolize the response of doctors locally and around the country.

Pincered by rising costs and eroding reimbursements, and resentful of what they regard as a long-standing and unfair financial burden, some doctors, especially pediatricians and gynecologists who are most likely to be asked for the vaccine, are refusing to buy it or restricting who receives the shots.

Discontent over the price of the vaccine -- the most expensive ever approved -- highlights a long-simmering dispute over reimbursement for immunizations, traditionally regarded as bedrock medicine. It is a dispute, experts say, with significant public health implications that has accelerated as the number of costly new vaccines has proliferated.

"This is a national issue that is affecting lots of people," said Benjamin Gitterman, president of the D.C. chapter of the American Academy of Pediatrics. "It's a matter of cash flow," Gitterman added. Some insurance companies are paying doctors $122 per shot -- just $2 more than the price doctors pay for a dose of Gardasil -- an amount not sufficient to cover the cost of stocking and administering the vaccine, doctors say. The problem is disproportionately affecting pediatricians, experts say, because they administer the majority of immunizations and are among the lowest-paid specialists.

"Some plans are saying I'll give you $90 -- and not a penny more," said Washington pediatrician Promise Ahlstrom.

Instead of routinely immunizing females between the ages of 9 and 26, the population for which the three-dose vaccine is approved, some doctors are handing patients a prescription to be filled at a pharmacy. Patients who do this, however, may be stuck with the tab: Many insurers, including CareFirst and Aetna, pay only for vaccines supplied by a doctor.

Other physicians are reserving Gardasil for patients whose insurers have agreed to pay what the doctor deems a "reasonable" fee -- usually a minimum of about $140. Still others are requiring payment from patients upfront.

The spotty availability of Gardasil is likely to complicate efforts by parents to comply with new laws in Virginia and the District. Both jurisdictions will require the vaccine for school entry with certain exceptions. (Maryland officials are studying whether to require the vaccine.) Doctors report a brisk demand for the vaccine, which prevents some strains of the ubiquitous human papillomavirus (HPV), linked to the development of cervical cancer.

Merck executives have said that the price of Gardasil is justified by its development costs and its value. Insurance company officials agree that the vaccine is expensive, but add that physicians are adequately compensated for providing it.

Many pediatricians see things differently.

"We shouldn't be expected to subsidize the public health system and perform our jobs at a loss," said Jon R. Almquist, chairman of the pediatrics academy task force on immunization, in a statement released last week. "We've carried this burden long enough."

Herschel R. Lessin, medical director of a large pediatric practice in Poughkeepsie, N.Y., that participates with 50 health plans, wholeheartedly agrees.

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