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Financing of Vaccine Delivery in Primary Care Practices

  • Mandy A. Allison
    Correspondence
    Address correspondence to Mandy A. Allison, MD, MSPH, University of Colorado, Department of Pediatrics, Mail Stop F443, 13199 E Montview Blvd, Suite 300, Aurora, CO 80045.
    Affiliations
    Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora

    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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  • Sean T. O'Leary
    Affiliations
    Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora

    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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  • Megan C. Lindley
    Affiliations
    National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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  • Lori A. Crane
    Affiliations
    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora

    Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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  • Laura P. Hurley
    Affiliations
    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora

    Division of Internal Medicine, Denver Health, Colo
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  • Brenda L. Beaty
    Affiliations
    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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  • Michaela Brtnikova
    Affiliations
    Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora

    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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  • Andrea Jimenez-Zambrano
    Affiliations
    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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  • Christine Babbel
    Affiliations
    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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  • Stephen Berman
    Affiliations
    Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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  • Allison Kempe
    Affiliations
    Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora

    Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora
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      Abstract

      Objective

      Vaccines represent a significant portion of primary care practice expenses. Our objectives were to determine among pediatric (Ped) and family medicine (FM) practices: 1) relative payment for vaccine purchase and administration and estimated profit margin according to payer type, 2) strategies used to reduce vaccine purchase costs and increase payment, and 3) whether practices have stopped providing vaccines because of finances.

      Methods

      A national survey conducted from April through September 2011 among Ped and FM practitioners in private, single-specialty practices.

      Results

      The response rate was 51% (221 of 430). Depending on payer type, 61% to 79% of practices reported that payment for vaccine purchase was at least 100% of purchase price and 34% to 74% reported that payment for vaccine administration was at least $11. Reported strategies to reduce vaccine purchase cost were online purchasing (81% Ped, 36% FM), prompt pay (78% Ped, 49% FM), and bulk order (65% Ped, 49% FM) discounts. Fewer than half of practices used strategies to increase payment; in a multivariable analysis, practices with ≥5 providers were more likely to use strategies compared with practices with fewer providers (adjusted odds ratio, 2.65; 95% confidence interval, 1.51–4.62). When asked if they had stopped purchasing vaccines because of financial concerns, 12% of Ped practices and 23% of FM practices responded ‘yes,’ and 24% of Ped and 26% of FM practices responded ‘no, but have seriously considered.’

      Conclusions

      Practices report variable payment for vaccination services from different payer types. Practices might benefit from increased use of strategies to reduce vaccine purchase costs and increase payment for vaccine delivery.

      Keywords

      What's New
      Practices report variable payment for vaccination from different payer types and payments often fail to cover the costs of vaccine delivery. Whereas some practices reported using strategies to reduce vaccine purchase cost, few used strategies to increase payment for vaccination.
      Vaccinating youth to protect them from vaccine-preventable diseases is a cornerstone of primary care and a great achievement in public health.
      • Centers for Disease Control and Prevention
      Achievements in public health, 1900-1999. Impact of vaccines universally recommended for children – United States, 1990-1998.
      Despite its critical importance, delivering vaccines to all youth can be a challenge for pediatric (Ped) and family medicine (FM) practices because of the high cost of purchasing, storing, tracking, and administering vaccines in a complicated, multipayer system.
      • O'Leary S.T.
      • Allison M.A.
      • Lindley M.C.
      • et al.
      Vaccine financing from the perspective of primary care physicians.
      • Freed G.L.
      • Cowan A.E.
      • Clark S.J.
      Primary care physician perspectives on reimbursement for childhood immunizations.
      • Campos-Outcalt D.
      • Jeffcott-Pera M.
      • Carter-Smith P.
      • et al.
      Vaccines provided by family physicians.
      • Tayloe Jr., D.T.
      Immunization financing: key area for American Academy of Pediatrics advocacy.
      These challenges have caused some practices to seriously consider whether to stop providing vaccines.
      • Centers for Disease Control and Prevention
      Achievements in public health, 1900-1999. Impact of vaccines universally recommended for children – United States, 1990-1998.
      • O'Leary S.T.
      • Allison M.A.
      • Lindley M.C.
      • et al.
      Vaccine financing from the perspective of primary care physicians.
      Practices must obtain and store at least 12 vaccine products to provide all Advisory Committee on Immunization Practices recommended vaccines for youth.

      Centers for Disease Control and Prevention. Immunization Schedules: Child and Adolescent Schedule. Available at: https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Accessed April 24, 2017.

      Whereas approximately half of the vaccine supply for children in the United States is purchased by the federal government through the Vaccines for Children (VFC) program and distributed to VFC providers, slightly less than half is purchased by Ped and FM practices serving privately insured patients. The private sector purchase price for these vaccines ranges from approximately $21 for 1 dose of the diphtheria, tetanus, and acellular pertussis vaccine to $178 for 1 dose of the 9-valent human papillomavirus vaccine.

      Centers for Disease Control and Prevention. Vaccines for Children Program (VFC). CDC Vaccine Price List. Available at: https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html. Accessed April 24, 2017.

      In addition to the upfront purchase cost of vaccines, practices incur additional product-related expenses: personnel costs, storage costs, insurance costs, and recovery costs due to inventory waste.
      • Lindley M.C.
      • Shen A.K.
      • Orenstein W.A.
      • et al.
      Financing the delivery of vaccines to children and adolescents: challenges to the current system.

      American Academy of Pediatrics. The Business Case for Pricing Vaccines. Available at: https://www.aap.org/en-us/Documents/immunizations_thebusinesscase.pdf. Accessed April 24, 2017.

      Next, practices must deliver the vaccines to their patients, incurring expenses including physician and staff time, medical equipment, and professional liability insurance.
      • Lindley M.C.
      • Shen A.K.
      • Orenstein W.A.
      • et al.
      Financing the delivery of vaccines to children and adolescents: challenges to the current system.

      American Academy of Pediatrics. The Business Case for Pricing Vaccines. Available at: https://www.aap.org/en-us/Documents/immunizations_thebusinesscase.pdf. Accessed April 24, 2017.

      Practices recover these expenses by receiving payment for vaccine purchase and administration; however, the amounts practices pay to purchase vaccines and they are paid for vaccine product and administration vary widely.
      • Freed G.L.
      • Cowan A.E.
      • Gregory S.
      • Clark S.J.
      Variation in provider vaccine purchase prices and payer reimbursement.
      • Coleman M.S.
      • Lindley M.C.
      • Ekong J.
      • Rodewald L.
      Net financial gain or loss from vaccination in pediatric medical practices.
      • Glazner J.E.
      • Beaty B.
      • Berman S.
      Cost of vaccine administration among pediatric practices.
      A cause of variation in vaccine costs and payments for privately insured patients is that practices typically must negotiate with manufacturers or distributors for purchase prices and with health plans for payment for vaccine administration.
      • Lindley M.C.
      • Shen A.K.
      • Orenstein W.A.
      • et al.
      Financing the delivery of vaccines to children and adolescents: challenges to the current system.
      VFC vaccines are provided at no cost to VFC providers, but these providers do not receive any additional payment for the expenses associated with vaccine storage and tracking. Medicaid payments for VFC vaccine administration are set by states with matching from the federal government.
      • Lindley M.C.
      • Shen A.K.
      • Orenstein W.A.
      • et al.
      Financing the delivery of vaccines to children and adolescents: challenges to the current system.

      Centers for Disease Control and Prevention. Vaccines for Children Program (VFC) - About VFC. Available at: https://www.cdc.gov/vaccines/programs/vfc/index.html. Accessed April 24, 2017.

      Recognizing the challenges and complexity of vaccine financing, the National Vaccine Advisory Committee (NVAC) published recommendations in 2009 ‘to create optimal approaches to vaccine financing in both the public and private sectors'.
      • National Vaccine Advisory Committee
      Financing vaccination of children and adolescents: National Vaccine Advisory Committee recommendations.
      These recommendations included strategies for vaccine manufacturers, federal and state government programs, health insurance plans, professional medical organizations, and medical providers. The Affordable Care Act (ACA) of 2010 included some provisions to maintain and improve children's access to vaccines including requiring nongrandfathered private health plans to cover all Advisory Committee on Immunization Practices recommended vaccines without a copay in the next plan year that occurs 1 year after their recommendation and increasing Medicaid payment for vaccine administration for 2 years.

      Tan LJ. Impact of the Affordable Care Act on Immunization. Available at: https://www.izsummitpartners.org/content/uploads/2012/NAIS/NAIS-1_tan_impact.pdf. Accessed April 24, 2017.

      United States Department of Health & Human Services. Key features of the Affordable Care Act by year. Available at: https://www.ncbi.nlm.nih.gov/books/NBK241383/.

      Although the ACA included these provisions, most factors that affect vaccine purchase price and reimbursement for vaccine delivery for privately insured patients are left up to vaccine manufacturers and health plans.
      Although previous studies have reported detailed vaccine expense and payment data from Ped and FM providers in a limited number of states,
      • Glazner J.E.
      • Beaty B.
      • Berman S.
      Cost of vaccine administration among pediatric practices.
      data about medical providers' use of strategies to improve financing of vaccine delivery, such as those recommended by the NVAC, are limited. We conducted this study in 2011 using a national sample of providers from Ped and FM practices to describe their experiences with vaccine financing with the intent to follow changes over time. Our objectives were to determine and compare among Ped and FM practices: 1) levels of payment for vaccine purchase and administration and estimated profit margin for vaccine delivery according to payer type, 2) strategies used to reduce vaccine purchasing costs and increase payment for vaccine purchase and administration, and 3) whether practices have stopped providing vaccines to patients because of financial concerns.

      Methods

      The Vaccine Policy Collaborative Initiative, a program designed collaboratively with the Centers for Disease Control and Prevention (CDC) to assess primary care physicians' attitudes about vaccine-related issues, administered a survey to a national sample of Ped and FM physicians. The human subjects review board at the University of Colorado approved this study as exempt research.

      Study Population

      Physicians were recruited from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP). These physicians agreed to respond to several surveys annually. Physicians were excluded if they were in training, did not practice in the United States, or practiced <50% of the time in a primary care setting. A quota strategy was used to ensure that our physician sample was representative of the AAP and AAFP memberships on the basis of a sampling matrix including region of the country, practice setting, and practice location. Cells in the matrix were filled by randomly selecting from all of the recruits to yield a total of approximately 400 physicians in the Ped sample and 400 in the FM sample. This quota sampling strategy has been described in more detail in a previous publication.
      • Crane L.A.
      • Daley M.F.
      • Barrow J.
      • et al.
      Sentinel physician networks as a technique for rapid immunization policy surveys.
      This analysis includes physicians who classified themselves as working in single-specialty, private practices because our preliminary data suggested that physicians working in multispecialty practices, sites within a health maintenance organization (HMO) or managed care organization (MCO), and sites in an academic or public health setting were not knowledgeable about vaccine financing issues. Physicians living in universal purchase states with a system to collectively purchase vaccines for all children regardless of insurance type, were excluded because many of the questions on the survey were not relevant to them. At the time of this survey, 13 states collectively purchased some or all vaccines: Alaska, Hawaii, Massachusetts, Maine, North Carolina, New Hampshire, New Mexico, Rhode Island, South Dakota, Vermont, Washington, Wisconsin, and Wyoming. Among all of the physicians in our original samples, 56% (232 of 413) of Ped and 46% (198/427) of FM practitioners worked in single-specialty, private practices and did not practice in these 13 states. In comparison, approximately 44% of all Ped AAP members practice in a single-specialty, private practice, and approximately 47% of FM AAFP members practice in a privately-owned medical practice.

      American Academy of Family Physicians. Table 4: Selected Practice Characteristics of Active AAFP Members (as of December 31, 2016). Available at: http://www.aafp.org/about/the-aafp/family-medicine-facts/table-4.html. Accessed April 24, 2017.

      American Academy of Pediatrics, Division of Health Services. Pediatricians' Practice and Personal Characteristics: US only, 2016. Available at: https://www.aap.org/en-us/professional-resources/Research/pediatrician-surveys/Pages/Personal-and-Practice-Characteristics-of-Pediatricians-US-only.aspx. Accessed April 24, 2017.

      Questionnaire Design

      The questionnaire was developed with input from the CDC. It was pretested in advisory committees of Ped and FM practices from across the United States and was pilot tested among 39 Ped and FM practitioners, most of whom were in single-specialty, private practice settings. The questionnaire comprised 2 sections—the first specifically for physicians and the second for these physicians or another member of the practice who was most knowledgeable about vaccine financing. Data from the first section using the full sample of Ped and FM practitioners (not limited to single-specialty, private practice) have been published previously.
      • O'Leary S.T.
      • Allison M.A.
      • Lindley M.C.
      • et al.
      Vaccine financing from the perspective of primary care physicians.
      The second section is the focus of this report, which includes entirely distinct questions. It included a series of 22 questions regarding payment for vaccine purchase by private fee for service (FFS) insurance, private preferred provider organizations (PPOs), MCOs, or HMOs, and the Children's Health Insurance Program (CHIP). These questions used 5 categorical response options ranging from ‘less than 80% of purchase price’ to ‘greater than 120% of purchase price’ as well as ‘payment is too variable to answer’ and ‘do not see patients in this category’ options. Other questions were about reimbursement for vaccine administration according to payer type with response options ranging from ‘most pay less than or equal to $5’ to ‘most pay greater than or equal to $25.’ The questionnaire also included items about providers' perceptions of profit margin for vaccine delivery according to payer type. Participants were asked how often they used a variety of methods to purchase vaccines and negotiate payment for vaccine purchase and administration. They were also asked whether they had stopped purchasing one or more vaccines because of financial concerns in the past year. Finally, they were asked whether they had stopped providing certain vaccines on the basis of payer type.

      Survey Administration

      The survey was administered between April and September 2011 via Internet or postal mail depending on physician preference. The Internet group received an initial e-mail with a link to the survey and up to 11 e-mail reminders to complete the survey or provide the contact information for another person in the practice who could. The Internet nonresponders also received up to 4 paper surveys via postal mail. The mail group received an initial mailing and up to 6 mail requests to complete the survey or provide the contact information for a person who could. If a physician provided the name of a more knowledgeable person, that person was contacted with up to 3 e-mails, 3 postal mailings, and 2 phone calls.

      Analysis

      Analyses were conducted between January 2012 and June 2016. Internet and mail surveys were pooled for all analyses because provider attitudes have been reported to be comparable when obtained by either method.
      • Atkeson L.R.
      • Adams A.N.
      • Bryant L.A.
      • et al.
      Considering mixed mode surveys for questions in political behavior: using the Internet and mail to get quality data at reasonable costs.
      • McMahon S.R.
      • Iwamoto M.
      • Massoudi M.S.
      • et al.
      Comparison of e-mail, fax, and postal surveys of pediatricians.
      Comparisons were made between Ped and FM practices using chi-square or Mantel-Haenszel chi-square tests. Multivariable analyses were conducted for 2 outcomes: reported use of strategies to increase vaccine payment and the extent that vaccines were reported to be a moderate/major focus of negotiation with health plans. For the outcome about use of strategies to increase vaccine payment, a composite variable was created that was ‘yes’ if the respondent reported use of any one of the 3 strategies queried and was ‘no’ if the respondent did not use any of the 3 strategies. For both multivariable models, the predictor variables were: specialty, practice location, practice region, percent of patients with private insurance, and median number of providers in the practice. Predictor variables with a P value of .25 or less were included in a multivariable logistic regression model. Variables were retained in the final model if their P values were <.05.

      Results

      Among the target population for our study, single-specialty private practices not in universal purchase states, the overall response rate was 51% (221 of 430) with 56% of physicians or representatives from Ped practices (129 of 232) and 46% of physicians or representatives from FM practices (92 of 198) who responded (Table 1). There were no significant differences between respondents and nonrespondents for key characteristics. One Ped and 5 FM physicians reported that they did not provide vaccines to patients aged 0 to 18 years old and were excluded from further analyses. Most surveys (64% Ped, 60% FM) were completed by staff physicians or managing partners. The remainder were completed by office managers (31% Ped, 26% FM), nurses (2% Ped, 6% FM), and medical assistants (2% Ped, 3% FM).
      Table 1Characteristics of Survey Respondents and Nonrespondents According to Specialty
      Only private, single specialty practices that are not in a Universal Purchase state were included.
      VariableFamily Medicine (n = 198)Pediatrics (n = 232)
      Responder (n = 92)Nonresponder (n = 106)PResponder (n = 129)Nonresponder (n = 103)P
      Male sex60%67%0.2948%38%0.15
      Location0.140.50
       Urban34%22%42%50%
       Suburban40%50%49%42%
       Rural27%28%9 %9%
      Region0.100.59
       Midwest29%25%18%20%
       Northeast14%12%25%27%
       South33%49%43%34%
       West24%14%15%19%
      Mean (SD) age, years52 (9)54 (11)0.6151 (9)50 (12)0.23
      Median number of providers430.23550.79
      Percentage of patients with private insurance
       <50%34%28%
       50-74%29%37%
       75-100%37%35%
      Percentage of patients with Medicaid
       <25%83%69%
       25-50%11%18%
       >50%6%13%
      Only private, single specialty practices that are not in a Universal Purchase state were included.

      Level of Payment for Vaccine Purchase and Administration and Estimated Profit Margin

      Table 2 shows respondents' estimated payments for vaccine purchase and administration according to payer type. Some respondents (5%–20%) noted that payment was too variable to answer these questions. FM respondents reported lower relative payments by MCO/HMOs and CHIP compared with Ped respondents (P < .05). After excluding respondents who reported ‘payment is too variable to answer,’ the proportion of practices that reported that payment for vaccine purchase was 100% or more of purchase price was 79% (95% confidence interval (CI), 73–85) for FFS, 77% (95% CI, 70–83) for PPO, 68% (95% CI, 60–75) for MCO/HMO, and 61% (95% CI, 49–72) for CHIP. For vaccine administration, FM respondents reported a lower level of payment by Medicaid compared with Ped respondents (P < .05). After excluding respondents who reported ‘payment is too variable to answer,’ the proportion reporting that payment for vaccine administration was $11 or more was 74% (95% CI, 67–80) for FFS, 74% (95% CI, 67–80) for PPO, 57% (95% CI, 49–65) for MCO/HMO, 37% (95% CI, 27–47) for CHIP, and 34% (95% CI, 26–42) for Medicaid. When asked how their profit margin for vaccine delivery had changed in the previous 3 years, 25% of Ped and 15% of FM respondents reported an increase, 38% of Ped and 49% of FM respondents reported no change, and 37% of Ped and 36% of FM respondents reported a decrease (P = .16 for comparison between specialties).
      Table 2Practices' Reported Level of Payment for Vaccine Purchase and Vaccine Administration According to Payer Type
      Pediatrics and family medicine combined. Physicians responding “Do not see patients in this [payer] category” were excluded from the analyses for that category.
      Relative payment for vaccine purchaseFee for Service (n = 202)PPO (n = 200)MCO/HMO (n = 185)Medicaid
      Medicaid is not included for vaccine purchase because vaccine is provided to practices through the Vaccines for Children program.
      CHIP (n = 98)
       <80% of purchase price5%5%7%NA11%
       80%–99% of purchase price12%15%21%NA19%
       100%–109% of purchase price41%46%43%NA40%
       110%–119% of purchase price20%16%12%NA8%
       >120% of purchase price6%4%4%NA0%
       Payment is too variable to answer16%15%14%NA21%
      Payment for vaccine administrationFee for Service (n = 201)PPO (n = 199)MCO/HMO (n = 180)Medicaid (n = 156)CHIP (n = 108)
       Most pay ≤$53%3%11%19%20%
       Most pay $6–1019%20%26%44%37%
       Most pay $11–1735%33%27%25%25%
       Most pay $18–2422%23%16%6%6%
       Most pay ≥$257%8%6%1%3%
       Payment is too variable to answer14%14%13%5%9%
      PPO indicates preferred provider organization; MCO/HMO, managed care organization/health maintenance organization; CHIP, Children's Health Insurance Program; and NA, not applicable.
      Pediatrics and family medicine combined. Physicians responding “Do not see patients in this [payer] category” were excluded from the analyses for that category.
      Medicaid is not included for vaccine purchase because vaccine is provided to practices through the Vaccines for Children program.

      Strategies to Reduce Vaccine Purchase Cost and Increase Payment

      Among the 96% of respondents from practices (207 of 216) that saw patients with any type of private insurance, several strategies to purchase vaccines for privately insured patients were reported with Ped practices more likely to report using most strategies (Fig. 1). The most commonly used strategies were online purchasing discounts (81% Ped and 36% FM practices always/frequently used; P < .0001 for comparison between Ped and FM practices), prompt pay discounts (78% Ped, 49% FM practices; P = .0001), bulk order discounts (65% Ped, 49% FM practices; P = .04), group purchasing (69% Ped, 42% FM practices; P = .0006), and promotional pricing (69% Ped and 33% FM practices; P < .0001).
      Figure thumbnail gr1
      Figure 1Practices' reported strategies for purchasing vaccines for privately insured patients (n = 127 pediatric [PEDS], n = 80 family medicine [FM] practitioners). *P < .05 for comparison between specialties (Mantel-Haenszel chi-square); PEDS practitioners more likely to use all strategies. Percentages might not add up to 100% because of rounding. IPA indicates independent practice association; CDC, Centers for Disease Control and Prevention.
      Fewer than half of respondents reported negotiating regarding payment for vaccines (44% Ped, 33% FM practices; P = .10), administration fees (44% Ped, 35% FM practices; P = .21), and providing health plans with information about how much vaccine purchase and administration was costing their practice (47% Ped, 38% FM practices; P = .20). In the multivariable analysis, only practice size was associated with reporting use of any strategy to increase payment for vaccine delivery. The adjusted odds ratio for practices with 5 or more providers was 2.65; 95% CI, 1.51–4.62 compared with practices with fewer than 5 providers. When asked to what extent vaccines were a focus of negotiation with health plans, 26% of Ped and 44% of FM practitioners responded ‘not at all,’ 20% of Ped and 36% of FM practitioners responded ‘a little,’ 27% of Ped and 19% of FM practitioners responded ‘moderately,’ and 27% of Ped and 1% of FM practitioners responded ‘a major focus.’ In the multivariable analysis, only Ped specialty was associated with reporting that vaccines were a moderate or major focus (adjusted odds ratio, 4.5; 95% CI, 2.3–8.3).

      Decision to Stop Providing Certain Vaccines Because of Financial Concerns

      When asked if they had stopped purchasing 1 or more vaccines for youth because of financial concerns, 12% of Ped and 23% of FM practitioners responded ‘yes,’ 24% of Ped and 26% of FM practitioners responded ‘no, but have seriously considered,’ and 64% of Ped and 51% of FM practitioners responded ‘no’ (P = .06 for comparison between Ped and FM practices). Among physicians who reported stopping or seriously considering stopping the purchase of 1 or more vaccines (n = 89), the most important reasons were inadequate payment for the cost of the vaccine, the upfront costs of purchasing the vaccine, and inconsistent coverage of the vaccine across payers (Fig. 2).
      Figure thumbnail gr2
      Figure 2Practices' reported reasons for seriously considering or stopping purchase of 1 or more vaccines (n = 89). Percentages might not add up to 100% because of rounding. PEDS indicates pediatric; FM, family medicine; and VFC, Vaccines for Children.
      When asked if they had stopped giving certain vaccines to patients on the basis of payer type, 18% of Ped and 9% of FM practitioners responded ‘yes,’ 14% of Ped and 26% of FM practitioners responded ‘no, but have seriously considered,’ and 68% of Ped and 65% of FM practitioners responded ‘no’ (P = .04 for comparison between Ped and FM practices).

      Discussion

      In a survey conducted in 2011, many respondents from private, single-specialty practices reported that payments from all types of payers fail to cover the costs of vaccine delivery. Depending on payer, 21% to 39% reported that they were paid less than the vaccine purchase price. Using $11 as a low cost estimate for vaccine administration,
      • Glazner J.E.
      • Beaty B.
      • Berman S.
      Cost of vaccine administration among pediatric practices.
      most practices indicated that Medicaid and CHIP payment was less than the cost of vaccine administration. Using the AAP recommended level of payment for first vaccine administration,

      American Academy of Pediatrics. The Business Case for Pricing Vaccines. Available at: https://www.aap.org/en-us/Documents/immunizations_thebusinesscase.pdf. Accessed April 24, 2017.

      $25, more than 75% of practices indicated that all payer types provided less than the cost of vaccine administration. Although most respondents reported using at least 1 strategy to increase profitability, few reported negotiating with vaccine manufacturers or health plans. Some practices reported stopping purchase of certain vaccines because of cost and stopping administration of vaccines to patients with certain types of insurance, which might create disparities in vaccine coverage and, ultimately, vaccine-preventable disease incidence.
      Findings from our survey are similar to studies of the cost and profitability of vaccine delivery conducted in 2007.
      • Freed G.L.
      • Cowan A.E.
      • Gregory S.
      • Clark S.J.
      Variation in provider vaccine purchase prices and payer reimbursement.
      • Coleman M.S.
      • Lindley M.C.
      • Ekong J.
      • Rodewald L.
      Net financial gain or loss from vaccination in pediatric medical practices.
      • Glazner J.E.
      • Beaty B.
      • Berman S.
      Cost of vaccine administration among pediatric practices.
      In these studies notable variation in vaccine purchase price across practices and variation in payment for vaccine purchase and administration across vaccines, payer types, and practices was reported. The variability in payment across payers and across different vaccines might make it difficult for practices to assess whether they are profiting or losing money by delivering vaccines. In Freed and colleagues' 2007 study, approximately half of practices reported that they had experienced a decrease in profit margin in the previous 3 years.
      • Freed G.L.
      • Cowan A.E.
      • Clark S.J.
      Primary care physician perspectives on reimbursement for childhood immunizations.
      In 2011, we found that approximately one-third of practices reported a perceived decrease in profit margin. This difference could have several causes including differences in study design and practices' challenges with determining profitability in light of the complex multipayer system, health plans might have increased payment because of policy changes, and practices might have used strategies to decrease the cost of vaccine delivery.
      In 2009, the NVAC recommended that medical providers take advantage of volume ordering discounts when purchasing vaccines from manufacturers by participating in purchasing pools with other providers. Although many practices in our survey reported doing this, 24% of Ped and 39% of FM practitioners reported that they rarely participated in a pool. NVAC also recommended that professional medical societies should provide their members with technical assistance, and the AAP has done this. The AAP recommends that practices benchmark vaccine price against CDC pricing, participate in pools for vaccine purchasing, and negotiate with health plans to improve payment for vaccine delivery. It provides several resources to help practices implement these strategies.
      • Sobczyk E.
      Vaccine finance resources for physicians.
      We found a small percentage of practices that reported benchmarking against CDC pricing and negotiating with vaccine manufacturers, distributors, or health plans, with larger practices more likely to report using specific strategies to increase payment for vaccine delivery and Ped practitioners more likely to report vaccine delivery as a major focus of negotiation.
      Expecting use of multiple strategies to reduce the cost of vaccine purchase and increase payment for vaccine purchase and administration could put a heavy burden on primary care providers. Compared with Ped, FM practices must stock a larger number of vaccines so they can provide vaccines for all ages, which could further increase the burden of negotiating the best price. Because they serve a wider age range with fewer patients in each group, they might need a smaller number of each type of vaccine, which could makes it harder to negotiate lower vaccine purchase prices or take advantage of bulk purchasing discounts.
      • Campos-Outcalt D.
      • Jeffcott-Pera M.
      • Carter-Smith P.
      • et al.
      Vaccines provided by family physicians.
      Although FM practices provide less than 25% of all office visits for youth, visits to FM practitioners are more common for youth covered by Medicaid, living in rural areas, and living in the Midwest and western regions of the United States.
      • Freed G.L.
      • Clark S.J.
      • Konrad T.R.
      • Pathman D.E.
      Variation in patient charges for vaccines and well-child care.
      • Cohen D.
      • Coco A.
      Trends in well-child visits to family physicians by children younger than 2 years of age.
      • Zimmerman C.M.
      • Bresee J.S.
      • Parashar U.D.
      • et al.
      Cost of diarrhea-associated hospitalizations and outpatient visits in an insured population of young children in the United States.
      FM practitioners are faced with more challenges to making vaccine delivery profitable compared with Ped practitioners, and we found they were less likely to use strategies to increase profitability. Therefore, interventions and policies for FM practitioners to help improve profitability of vaccine delivery to prevent disparities in access to vaccines are needed.
      This study was conducted in the early stages of implementation of the ACA. Although the ACA did make changes to improve access to vaccines for Americans, most factors related to vaccine purchase price and payment for vaccine delivery for privately insured patients were not affected by the ACA, and they were left to vaccine manufacturers and health plans. In 2013 and 2014 (after we conducted our study), the ACA increased payment for vaccine administration by Medicaid to levels closer to estimates needed for financial sustainability. For example, in Colorado, payment for first vaccine administration increased from $6.59 to $21.68.

      Colorado Department of Health Care Policy & Financing. Provider bulletin. Available at: https://www.colorado.gov/pacific/sites/default/files/Bulletin_0715_B1500368.pdf. Accessed April 24, 2017.

      Because this payment increase was not a permanent change, our findings regarding Ped and FM perceptions of Medicaid payments are likely to still be relevant. Further study is needed to determine if the increase was associated with key outcomes such as increased financial sustainability of vaccine delivery.
      Our study has several limitations. It was limited to respondents from private, single-specialty Ped and FM practices that were not in universal purchase states; therefore, it might not be generalizable to multispecialty and other practice settings and might not be representative of all Ped and FM practices in the United States. Although we had respondents from around the nation, our sample size per state was too small to make state-level comparisons. Our study was conducted during the early stage of implementation of the ACA and did not address whether the ACA provisions described previously actually improved access to vaccines. Respondents' attitudes and practices might have differed from those of nonrespondents, and the response rate was acceptable (approximately 50%) but not optimal. The sentinel physicians in our national networks might differ from physicians overall, although our previous work suggests this is not the case. Our survey results represent reported practices and estimates of vaccine costs and payments; we did not observe actual practices or review specific vaccine purchasing or payment data. Finally, some respondents might not have been familiar enough with vaccine financing to respond accurately.

      Conclusion

      Vaccinating youth is a cornerstone of primary care; however, many practices report that the payments for vaccine purchase and administration do not cover their costs. Although practices can use a variety of strategies to decrease costs and increase payment for vaccine delivery, use of these strategies can be burdensome. Reforms to vaccine financing, such as those recommended by NVAC in 2009, should be implemented to reduce primary care practices' burden and increase profitability of vaccine delivery.

      Acknowledgments

      The findings and conclusions in this report are those of the authors and do not necessarily represent the official views of the CDC.
      Financial disclosure: This investigation was funded by the CDC and administered through the Rocky Mountain Prevention Research Center , University of Colorado Anschutz Medical Campus (grant 5U48DP001938 ).
      Authorship Statement: M.A.A. conceptualized and designed the study, contributed to the data collection instrument design, drafted the initial manuscript, and approved the final manuscript as submitted. M.C.L. contributed to the study design and data collection instrument design, reviewed and revised the manuscript, and approved the final manuscript as submitted. L.A.C. conceptualized and designed the study, designed the data collection instrument, reviewed and revised the manuscript, and approved the final manuscript as submitted. L.P.H. contributed to the study design and data collection instrument design, reviewed and revised the manuscript, and approved the final manuscript as submitted. S.T.O. conceptualized and designed the study, contributed to the data collection instrument design, reviewed and revised the manuscript, and approved the final manuscript as submitted. M.B. contributed to the study design and data collection instrument design, coordinated and supervised all data collection, reviewed and revised the manuscript, and approved the final manuscript as submitted. B.L.B. contributed to the study design carried out the initial and further analyses, reviewed and revised the manuscript, and approved the final manuscript as submitted. C.I.B. contributed to the study design and data collection instrument design, reviewed and revised the manuscript, and approved the final manuscript as submitted. A.J.-Z. contributed to the study design and data collection instrument design, coordinated data collection, reviewed and revised the manuscript, and approved the final manuscript as submitted. S.B. contributed to the study design and data collection instrument design, reviewed and revised the manuscript, and approved the final manuscript as submitted. A.K. conceptualized and designed the study, designed the data collection instrument, reviewed and revised the manuscript, and approved the final manuscript as submitted.
      Ethical approval: Institutional review board protocol number 04-0944.
      Previous presentations: Presented in part at the Pediatric Academic Societies' Annual Meeting, Boston, Mass, May 2012.

      References

        • Centers for Disease Control and Prevention
        Achievements in public health, 1900-1999. Impact of vaccines universally recommended for children – United States, 1990-1998.
        MMWR Morb Mortal Wkly Rep. 1999; 48: 243-248
        • O'Leary S.T.
        • Allison M.A.
        • Lindley M.C.
        • et al.
        Vaccine financing from the perspective of primary care physicians.
        Pediatrics. 2014; 133: 367-374
        • Freed G.L.
        • Cowan A.E.
        • Clark S.J.
        Primary care physician perspectives on reimbursement for childhood immunizations.
        Pediatrics. 2008; 122: 1319-1324
        • Campos-Outcalt D.
        • Jeffcott-Pera M.
        • Carter-Smith P.
        • et al.
        Vaccines provided by family physicians.
        Ann Fam Med. 2010; 8: 507-510
        • Tayloe Jr., D.T.
        Immunization financing: key area for American Academy of Pediatrics advocacy.
        Pediatrics. 2009; 124: S455-S456
      1. Centers for Disease Control and Prevention. Immunization Schedules: Child and Adolescent Schedule. Available at: https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Accessed April 24, 2017.

      2. Centers for Disease Control and Prevention. Vaccines for Children Program (VFC). CDC Vaccine Price List. Available at: https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html. Accessed April 24, 2017.

        • Lindley M.C.
        • Shen A.K.
        • Orenstein W.A.
        • et al.
        Financing the delivery of vaccines to children and adolescents: challenges to the current system.
        Pediatrics. 2009; 124: S548-S557
      3. American Academy of Pediatrics. The Business Case for Pricing Vaccines. Available at: https://www.aap.org/en-us/Documents/immunizations_thebusinesscase.pdf. Accessed April 24, 2017.

        • Freed G.L.
        • Cowan A.E.
        • Gregory S.
        • Clark S.J.
        Variation in provider vaccine purchase prices and payer reimbursement.
        Pediatrics. 2009; 124: S459-S465
        • Coleman M.S.
        • Lindley M.C.
        • Ekong J.
        • Rodewald L.
        Net financial gain or loss from vaccination in pediatric medical practices.
        Pediatrics. 2009; 124: S472-S491
        • Glazner J.E.
        • Beaty B.
        • Berman S.
        Cost of vaccine administration among pediatric practices.
        Pediatrics. 2009; 124: S492-S498
      4. Centers for Disease Control and Prevention. Vaccines for Children Program (VFC) - About VFC. Available at: https://www.cdc.gov/vaccines/programs/vfc/index.html. Accessed April 24, 2017.

        • National Vaccine Advisory Committee
        Financing vaccination of children and adolescents: National Vaccine Advisory Committee recommendations.
        Pediatrics. 2009; 124: S558-S562
      5. Tan LJ. Impact of the Affordable Care Act on Immunization. Available at: https://www.izsummitpartners.org/content/uploads/2012/NAIS/NAIS-1_tan_impact.pdf. Accessed April 24, 2017.

      6. United States Department of Health & Human Services. Key features of the Affordable Care Act by year. Available at: https://www.ncbi.nlm.nih.gov/books/NBK241383/.

        • Crane L.A.
        • Daley M.F.
        • Barrow J.
        • et al.
        Sentinel physician networks as a technique for rapid immunization policy surveys.
        EvalHealth Prof. 2008; 31: 43-64
      7. American Academy of Family Physicians. Table 4: Selected Practice Characteristics of Active AAFP Members (as of December 31, 2016). Available at: http://www.aafp.org/about/the-aafp/family-medicine-facts/table-4.html. Accessed April 24, 2017.

      8. American Academy of Pediatrics, Division of Health Services. Pediatricians' Practice and Personal Characteristics: US only, 2016. Available at: https://www.aap.org/en-us/professional-resources/Research/pediatrician-surveys/Pages/Personal-and-Practice-Characteristics-of-Pediatricians-US-only.aspx. Accessed April 24, 2017.

      9. 3rd ed. Internet, Mail and Mixed-Mode Surveys: The Tailored Design Method. vol 3. John Wiley Co, New York, NY2009
        • Atkeson L.R.
        • Adams A.N.
        • Bryant L.A.
        • et al.
        Considering mixed mode surveys for questions in political behavior: using the Internet and mail to get quality data at reasonable costs.
        Political Behavior. 2011; 33: 161-178
        • McMahon S.R.
        • Iwamoto M.
        • Massoudi M.S.
        • et al.
        Comparison of e-mail, fax, and postal surveys of pediatricians.
        Pediatrics. 2003; 111: e299-e303
        • Sobczyk E.
        Vaccine finance resources for physicians.
        Pediatrics. 2009; 124: S573-S576
        • Freed G.L.
        • Clark S.J.
        • Konrad T.R.
        • Pathman D.E.
        Variation in patient charges for vaccines and well-child care.
        Arch Pediatr Adolesc Med. 1996; 150: 421-426
        • Cohen D.
        • Coco A.
        Trends in well-child visits to family physicians by children younger than 2 years of age.
        Ann Fam Med. 2010; 8: 245-248
        • Zimmerman C.M.
        • Bresee J.S.
        • Parashar U.D.
        • et al.
        Cost of diarrhea-associated hospitalizations and outpatient visits in an insured population of young children in the United States.
        Pediatr Infect Dis J. 2001; 20: 14-19
      10. Colorado Department of Health Care Policy & Financing. Provider bulletin. Available at: https://www.colorado.gov/pacific/sites/default/files/Bulletin_0715_B1500368.pdf. Accessed April 24, 2017.