• Health reform
• EMRs
• Medicare
• Liability
• AMA House
• » More

• Contract Language
• Ethics Forum
• In the Courts
• Practice Management
• Technically Speaking
• » More

• Issue dates
• Regions
• Health plans
• Sections
• News briefs
• Columns
• Editorials
• Letters
• Series
• Writers
• Other years

• Search tips
• Email alert
• RSS
• Mobile
• Subscribe
• Institutions
• Staff directory
• Advertising
• Permissions
• Reprints
• News media
• Site guide
• Useful links
• About
• Premium
• Contact

• AMA Wire
• CPT
• DMPHP
• JAMA
• JAMA&Archives
• news@JAMA
• Virtual Mentor
• Physician jobs

Medicare hikes pay for pneumonia shots

The administration has worked to remove barriers to increasing immunization rates.

By Markian Hawryluk, amednews staff. Sept. 8, 2003.

• PRINT|
• E-MAIL|
• RESPOND|
• REPRINTS|
• SHARE
•  

Washington -- In a five-line paragraph posted on its Web site, the Centers for Medicare & Medicaid Services announced in late August that the Medicare Part B payment for pneumococcal vaccine would increase to $18.62 effective Oct. 1.

But even the few physicians who have seen the announcement may not realize the payment increase is only the latest in a long series of steps the Bush administration has taken to help reduce barriers to immunization for both pneumonia and influenza and to reach its goal of nearly universal vaccination for at-risk beneficiaries.

When coupled with a 94% increase in March in payment for the administration of pneumococcal vaccine, the change will mean physicians will receive average total reimbursement of $26.58 after Oct. 1 for providing the vaccine, up from $17.08 at the start of the year.

And CMS has moved to make immunization easier in clinics and other health facilities. The agency is expected to issue a new regulation on Oct. 2 allowing hospitals, nursing homes and home health agencies to use standing orders to immunize their patients. The rule will authorize pharmacists and nurses to administer vaccinations under a institution- or physician-approved protocol without requiring physicians to first examine the patients.

Additionally, CMS indicated that small physician practices and facilities that are otherwise exempt from Health Insurance Portability and Accountability Act electronic transaction standards could electronically submit a single bill for all vaccinations without triggering HIPAA rules.

Physician groups, including the American Medical Association, which fought hard for the increase, applauded the latest payment boost and the announcement's timing.

"The CMS information is particularly timely since over 70% of the pneumococcal vaccine purchased last year occurred in the four-month period of August through November," said AMA Trustee Ron Davis, MD.

In the past, CMS has announced payment increases for vaccines after they had been implemented. But the agency agreed to give advance notice of the new rate hike because physicians often order pneumonia and flu vaccine at the same time, just before the start of the flu season. Now physicians will know what the payment will be before they order, Dr. Davis said.

"Seniors' ability to access this vaccine for pneumonia is instrumental in fighting it," he said. "We hope that CMS' rate correction notice will help increase resistance to pneumonia through greater access to the vaccine."

Access to both vaccines has been a problem in recent years, primarily due to a shortage of flu vaccine in 2000 and 2001, but also due to payment levels, said Ron Bangasser, MD, a family physician from Redlands, Calif., and president of the California Medical Assn.

"Not having it certainly makes it difficult giving it," Dr. Bangasser said. "But what was also a very large barrier for physicians, especially in single office or small group practices, was the purchase and cost of vaccines."

Getting patients, and physicians, back

Faced with difficulties in acquiring and paying for the vaccine, many physicians began to refer patients to flu clinics or other facilities for their shots, he said. Immunization advocates have pressed for vaccination whenever the patient interacts with the health care system. Referrals mean many won't go and won't get their shots.

Now the health care system must battle to win back physicians who experienced problems. The Centers for Disease Control and Prevention has indicated it does not expect any shortages in flu vaccines this year and has retracted recommendations that high-risk patients be immunized first.

Dr. Bangasser can still remember when flu vaccines cost $16 for 10 doses. Now a single dose costs that much. His practice immunizes more than 30,000 individuals, purchasing almost $200,000 in flu vaccine. But smaller practices can't get such economies of scale.

A recent study on the economics of influenza vaccines found that it cost large group practices $10.21 to give a flu shot in 2001, while it cost solo practices $12.83. The Medicare payment rate in 2001 was $11.71.

About 44% of the physicians surveyed in the study said they already vaccinate all eligible patients, but another 25% said a payment increase would encourage them to adopt new vaccination strategies.

Jim Martin, MD, a family physician from San Antonio and president of the American Academy of Family Physicians, said he often hears doctors complain about the payment rate for influenza vaccines.

"It's another one of those frustrations of Medicare not reimbursing at the appropriate level," Dr. Martin said. "I didn't hear from of any colleagues who weren't giving it. They were all very angry and frustrated last year. They were having to absorb the cost of the vaccine in an already depressed environment."

CMS is expected to confirm a payment rate of $9.95 for influenza vaccine, although at press time at the start of the flu immunization season, it had yet to do so. Payments for pneumonia shots had been lower because CMS was including the prices of repackagers in its calculation. After Oct. 1, CMS will only consider the price listed by Merck, the vaccine's manufacturer.

Medicare pays for physician-administered drugs, including vaccines, at the doctor's acquisition cost or at 95% of the average wholesale price reported by manufacturers, whichever is lower. CMS also is considering reforms of its drug payment system for implementation in 2004.

Money isn't enough

Although the changes may remove additional barriers to increasing vaccination, it will take much more than just money to reach public health targets, Dr. Bangasser said.

The federal government's Health Goals 2010 initiative set target flu and pneumonia immunization rates at 90% of at-risk individuals, which includes all patients older than 65. Yet immunization rates are languishing in the 60% range for flu shots and even lower for pneumonia shots.

"We got past the dollars part of it, now we need to get the number of shots up," Dr. Bangasser said. "One death is too many. We need to do a better job."

Back to top

 ADDITIONAL INFORMATION: