Shen AK. Pediatrics. 2011;doi:10.1542/peds.2011-0025.
Health care providers received more than $20 less from commercial payers
for use of a combination vaccine compared with when individual component
vaccines were used, according to study results.
The researchers aimed to evaluate how use of a combination vaccine
(Pediarix, GlaxoSmithKline) would affect providers vs. use of equivalent
component vaccines for children aged 1 year or younger.
Charge and payment information submitted by health care providers to
insurance payers were analyzed using a subscription remittance billing service.
The study period was June 2007 to July 2009. The analysis accounted for
characteristics of both provider and payer, the ratio of vaccine product to
immunization administration codes, payer comments and computed total charges
and payments to providers.
Pediatricians accounted for 74% of providers, and commercial payers
— primarily managed care — accounted for 75% of payers. For most
claims, a 1:1 ratio was observed between the number of vaccine products and the
number of immunization codes. No adjustment was made by the payer in 20% of the
claims that were paid. Adjustments for charges that exceeded the contract
arrangement or fee schedule were made in 76% of claims.
Providers received $23 less from commercial payers when they used the
combination vaccine compared with when they used the component vaccines. They
received $13 less from Medicaid for use of the
combination compared with use of the components.
“The mean commercial payment was greater for age-specific Current
Procedural Terminology [immunization administration] codes 90465 and 90466 than
for non–age-specific codes 90471 and 90472, whereas the reverse was true
for Medicaid,” the researchers wrote.
They said financial barriers are associated with use of
combination vaccines, and new immunization
administration codes should be monitored to correct these barriers.
Disclosure: The study was conducted under contract with SDI
Health. One of the researchers, Farid Khan, MPH, is an employee of SDI
Shen et al have carefully examined the financial impact to practices
that use a combination vaccine (Pediarix, GlaxoSmithKline) vs. equivalent
component vaccines by studying billing data of charges and payments by insurer,
both commercial and Medicaid, from a large subscription remittance billing
service serving private practice office-based physicians. They conclude that
physicians immunizing children face reduced payments when choosing to provide
combination vaccines, the preferred product of as recommended by the CDC and
the AAP. This equals $22.94 less from commercial payers and $13.42 less from
Medicaid. This difference primarily reflects the difference in payment for
immunization administration, a separate CPT coded charge(s).
What does the study reflect? Coding is nearly impossible to understand,
ever changing in complexity and extremely cumbersome to track at the individual
practice level. New codes for vaccine administration have been in place since
January 2011, and in my practice we have received $0 for administration using
the new codes since that time.
It is clear that no matter the "better-practice" intent of coding
changes, usually driven by an attempt to reimburse for the professional time
required to properly inform families and vaccinate our youth, that as
pediatricians we are woefully underpaid to perform what is arguably our most
important and only evidence-based practice, even in managed-care populations.
Despite this, we continue to be dedicated to our patients and do a remarkable
job immunizing them.
William T. Gerson, MD
in Children Editorial Board member
Disclosure: Dr. Gerson reports no relevant financial disclosures.