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.
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, 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.
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 of Columbia. Both jurisdictions will require the vaccine for school entry with certain exceptions. Doctors report a brisk demand for the vaccine, which prevents some strains of the human papillomavirus (HPV), linked to the development of cervical cancer.
Merck executives have said the price of Gardasil is justified by its development costs and its value. Insurance company officials agree the vaccine is expensive, but add 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.
Herschel R. Lessin, medical director of a large pediatric practice in Poughkeepsie, N.Y., that participates with 50 health plans, agrees. "I have to pay for nursing time, supplies, syringes, alcohol pads, dropped doses and time to explain it," Lessin said of the ancillary costs. "And when insurance companies decide to pay me $122 per dose and take three months to pay, I can't afford to do it. For insurance companies that are paying me $140 or $150 a dose, I'll give it." In other cases, Lessin said, he is giving patients a prescription to be filled at a pharmacy and administering the vaccine for a $25 fee.
His patients, Lessin added, "understand this."
Ahlstrom said her partners have agreed to give Gardasil to patients who belong to NCPPO, the only plan in which her practice participates. The remaining two-thirds of her patients must pay for Gardasil shots upfront.
"I feel it's a really unfair situation to put pediatricians in," she said, adding that her partners decided they would not give Gardasil at a loss. Most parents, she added, are unaware that "doctors all the time give vaccines we lose money on."
Christina Sprague of Washington said she has spent several hours on the phone in recent months trying to find a doctor who will immunize her daughter. "It's been pretty frustrating," Sprague said. "This should be straightforward."
Linda Woolley, a lawyer who lives in the Washington area, said she called four doctors' offices recently seeking one that had the vaccine, which officials at CareFirst BlueCross BlueShield told her was covered under her plan.
None did, but a doctor in the office of Woolley's OB-GYN, Mark Reiter, wrote a prescription and agreed to give the shot to Woolley's teenage daughter. But after Woolley spent $181.99 for the first dose of the vaccine from CVS, CareFirst rejected the claim, saying it wasn't covered because the vaccine had not been supplied by a physician.
Reiter said his practice doesn't buy Gardasil because the $2 reimbursement rate quoted by insurance companies "isn't worth it."
Woolley regards her situation as a Catch-22: "I find it curious that states are mandating this" but consumers have trouble getting the vaccine.
CareFirst spokesman Jeff Valentine said the company is looking into several similar complaints from subscribers. "We are in the process of examining our rates," said Valentine, adding that several physicians have complained about low reimbursements. But he said CareFirst, one of the largest insurers in the Washington area, is "competitive with what other insurers are paying," although he declined to discuss fees. Recently Cigna and UnitedHealthcare announced they were raising reimbursement rates for Gardasil.
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 also can 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. 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 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.
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.
Three shots in six months
The HPV vaccine is given through a series of three shots over a six-month period. The second and third doses should be given two and six months, respectively, after the first dose.
Q: Will the HPV vaccine be covered by insurance plans?
A: While some insurance companies may cover the vaccine, others may not. Most large plans usually cover the costs of recommended vaccines. However, there is often a short lag time after a vaccine is recommended before it is available and covered by health plans.
Q: What kind of government programs may be available to cover the HPV vaccine?
A: Federal health programs such as Vaccines for Children will cover the HPV vaccine. The federal program provides free vaccines to children and teens under age 19 who are uninsured, Medicaid-eligible, American Indian or Alaska natives. More than 45,000 sites provide these vaccines, including hospitals and private and public clinics. The program also allows children and teens to get vaccines through Federally Qualified Health Centers and Rural Health Centers if their private health insurance does not cover the vaccine.
Some states also provide free or low-cost vaccines at health department clinics to people without health insurance coverage for vaccines.
Q: Will girls/women who have been vaccinated still need cervical cancer screening?
A: Yes, for three reasons. First, the vaccine will not protect against all types of HPV that cause cervical cancer, so vaccinated women still will be at risk for some cancers. Second, some women may not get all required doses of the vaccine (or they may not get them at the right times), so they may not get the vaccine's full benefits. Third, women may not get the full benefit of the vaccine if they receive it after they've already acquired one of the four HPV types.
Q: Should girls/women be screened before getting vaccinated?
A: No. Girls/women do not need to get an HPV test or Pap test to determine whether they should get the vaccine. An HPV test or a Pap test can tell that a woman may have HPV, but these tests cannot tell the specific HPV type(s) that a woman has. Even girls/women with one HPV type could get protection from the other HPV types they have not yet acquired.
Q: Will girls be required to get vaccinated before they enter school?
A: No federal laws require children or adolescents to get vaccinated. All school and day-care entry laws are state laws, so they vary from state to state. To find out what vaccines are needed for children or teens to enter school or day care in your state, check with your state health department or board of education.
