Pediatrics

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 Health.

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
Infectious Diseases in Children Editorial Board member

Disclosure: Dr. Gerson reports no relevant financial disclosures.

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