Who Gets Stuck?

Walt Cherniak, a spokesman for Aetna, said the company pays doctors $120 plus a 5 percent markup -- $6 -- and an administrative fee of $8 to $15. In some cases doctors can also bill for the office visit, he said.

"We believe our reimbursement is reasonable and sufficient" to cover doctors' costs, Cherniak said. "And we encourage members to ask physicians for the vaccine."

The economics of providing vaccines has changed dramatically in the past two decades, noted Anne Francis, an associate clinical professor of pediatrics at the University of Rochester School of Medicine. Twenty years ago it cost $150 to fully immunize a child with nine vaccines, she said. The current cost is $1,500, and the number of vaccines has jumped to about 35. These days, she said, there is little room to recoup the cost of a dropped syringe of vaccine, a child who pulls away, a patient who changes her mind at the last minute or refrigerated doses that must be discarded after a power failure.

"If I was a single practitioner, I would need to come up with $36,000 just to buy [the full three doses] of Gardasil for 100 patients," she said. "That's a lot of cash to put out," especially for small practices.

Some doctors say the benefits outweigh the problems.

"For the first six to 12 months [after a new vaccine is introduced], the insurance companies don't know what they're doing," said Northern Virginia pediatrician Gary Bergman. His large practice, he said, "probably breaks even" providing vaccines, which he regards as a core mission of pediatrics.

"Pediatricians are nickel-and-dimers," Bergman added.

Until recently, he and his partners were giving Gardasil shots to former patients over 21 -- until their risk management firm warned that doing so would result in an increase in liability premiums. "That's a shame, because a lot of patients said their [gynecologists] didn't carry it," Bergman said.

Officials at the American College of Obstetricians and Gynecologists say they are hearing about inadequate reimbursement from members who are reluctant to buy Gardasil.

"We need to make our members understand that [vaccines] are part of their practice," said Gregory Moore, director of student health services at the University of Kentucky and chairman of the ACOG's committee on gynecologic practice. Moore attributes some of the resistance to his specialty's lack of experience using vaccines.

April Rubin, one of the city's few remaining solo OB-GYNs, already understands this. Rubin, who practices on Capitol Hill, bought Gardasil and is giving it to current patients. She said about a dozen so far have requested it.

"My business manager doesn't think I should be doing it," Rubin said. "I lose money, but I do it as a service to my patients." ·

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