Make sure kids’ vaccines covered

In Georgia, more than half of children get their childhood immunizations through a family pediatrician. But problems with a federal program designed to make vaccinations more widely available may cause private-practice physicians to give up providing shots to their patients, even to those who are privately insured.

A survey published in the December issue of the medical journal Pediatrics confirms what many physicians have discovered on their own in recent years: There are wide disparities in how insurance companies pay for immunizations and in some cases, doctors who provide them lose money.

And if cost drives pediatricians and family-practice physicians out of the immunization business — the survey showed that was starting to happen — the fear is that public health clinics might be overwhelmed. That in turn could lead to new outbreaks of childhood diseases such as measles, mumps and rubella brought under control years ago by widespread immunization.

Ultimately, the way to finance this and other preventive-care measures lies in comprehensive reform of the nation’s health care system to put a higher premium on primary care services.

Several new vaccines — each expensive to develop and designed to prevent diseases beyond the scope of traditional childhood immunizations — have been introduced in the last few years, and insurance companies have moved slowly to reimburse physicians for their full costs. These include a $360, three-shot regimen for adolescent girls that prevents the most common strains of human pappilomavirus (HPV), a sexually transmitted disease; and a $190 shot to prevent against a rotavirus that causes severe and life-threatening diarrhea.

Public health officials are also stressing wider immunizations for more common illnesses, such as yearly influenza shots for older children and an $80 meningitis vaccine. The list of recommended vaccines for infancy through age 18 now costs roughly $1,600 in vaccines alone. Thirty years ago when there were fewer shots, the cost, adjusted for inflation, was about $60. In the last seven years alone the total cost of recommended vaccines has tripled.

In a way that’s a good thing — these vaccines are effective and reduce health care costs in the long run. But the transformation was not anticipated in 1994 when the federal government implemented the Vaccine for Children Act, a program that now spends about $3 billion annually. That program was designed to make it easier for parents to get their children’s immunizations handled by physicians while controlling costs and relieving pressure on public health clinics. The program reimburses doctors for the vaccines they provide as well as pay them a small administrative fee.

The program was inspired in part by a 1989 measles outbreak among children, when public health workers discovered that many parents had neglected to get their children immunized even though they had a family doctor.

The new program guaranteed payment to physicians who vaccinated kids through Medicaid. Within a few years private insurers began doing the same thing. Many created “well baby” benefit programs that covered the entire cost for immunizations and other childhood checkups.

Last year, immunization rates of American children reached all-time highs — more than 90 percent of kids are getting vaccinated against mumps, polio and hepatitis-B, for instance. Overall, 85 percent of all children now get all or some of their immunizations from private physicians. The Vaccine Act paid for about 55 percent of those children, mainly those covered by Medicaid or children’s insurance programs such as Georgia’s PeachCare for Kids. But even those government-subsidized vaccines are administered mainly by private-practice physicians.

Unfortunately, financing for the government program and commercial insurance has not kept pace with the demand for newer vaccines and the escalating costs. The disparities in payments have also gotten worse, as the Pediatrics survey found. For example, a doctor who administers a childhood vaccine against pneumococcal disease might lose as much as $11 when providing it to a child insured by one company, but profit as much as $40 for a child covered by a different health plan. Payments for a common chickenpox vaccine ranged from a $30 loss to a $30 profit.

More alarming still, many private insurance plans — those not underwritten by an employer and purchased on the open market — have high deductibles that sometimes require parents to pay for immunizations out of their own pocket. The fear is that many of them will simply go without, which could trigger new disease outbreaks.

Next to clean water and sanitation, the best public health investment governments can make is in vaccinations for common illnesses. As a new president and Congress begin the complicated process of reforming the nation’s health care financing system, the first order of business ought to be guaranteeing a complete round of immunizations for all children, whether through government programs or private insurance.

It’s the humane and economically smart thing to do.

— Mike King, for the editorial board (mking@ajc.com)