An Issue of Fair Reimbursement
by Pamela Mooman
A coalition of San Antonio pediatricians has
joined together, under the leadership of
spokesperson Juan Jose Ferreris, MD to
campaign for insurers to offer more fair compensation
for the costs associated with single dose vaccine
purchases and overhead costs related to product
storage, handling, and wastage.
“We are demanding that insurers pay for the true
single dose vaccine cost, as well as the costs associated
with storing and managing the vaccines,” says
Dr. Ferreris. “The base values used by insurers of
what our vaccine costs are simply are not reflective
of single-dose vaccine costs.”
Brandy McCray, MD is another San Antonio
pediatrician who is working with Dr. Ferreris to get
the word out about fair reimbursement for vaccines. “There is no specific amount for reimbursement,”
Dr. McCray says. “The vaccine reimbursements
they (insurers) provide are based on wholly
inaccurate data in the form of Average Sales Price.
This is a number that insurers buy from different
companies that is comprised of data collected from
the vaccine manufacturers.”
She adds that the data includes sales price to
both the private and public sector, which creates
the problem.
“The public sector purchases vaccines at half the
price of what private pediatricians pay,” Dr. McCray
says. “This artificially lowers the Average Sales Price
and, in turn, our reimbursements do not cover our
costs. Sometimes the reimbursements are less than
even our purchase cost of the vaccine, not including
any other expenses we incur.”
Drs. Ferreris and McCray are members of both
the San Antonio Pediatric Society, generally around
30 members, but recently swelling to almost 90,
and the American Academy of Pediatrics (AAP),
and almost all of the pediatricians joining this movement are board-certified and fellows
of the American Academy
of Pediatrics.
This group has grown quite vocal
of late, and Dr. Ferreris has been in
contact with pediatricians from Harris
County and from other states via a
Web blog set up by the AAP regarding
practice management issues.
In fact, the group has met with the
Texas Department of Insurance, Dr.
McCray says, without much success.
But the Texas Medical Association
is listening.
Dr. Ferreris, in early February, made
a presentation in Austin to the Council
on Socioeconomics and Public Health.
After the presentation and some discussion,
the council passed a resolution
supporting Dr. Ferreris’ position, and
that of the other pediatricians standing
as one behind him.
The resolution, calling for fair payment
for immunization by pediatricians,
asks the TMA to facilitate
legislative action that demands fair
payments. Several components of
it include:
• Mandating that insurers cover all
true costs of immunizations as
defined by the American Academy
of Pediatrics, using a nationally recognized
benchmark such as the
CDC private party single dose data;
• Include the Texas state revenue tax on
small business of 1 percent as well as
a reasonable profit margin to ensure
that primary care physicians can continue
vaccination programs and provide
for the health of Texas children.
“The AAP has been fighting this
fight for years now,” Dr. McCray says. “They publish a worksheet on vaccine
reimbursement to allow providers to
calculate their costs of purchasing vaccine
and separately for the administration.
Based on this, they have calculated
our costs for purchasing, storing,
and insuring to be anywhere
from 17 percent to 28 percent of our
purchase cost, not including the one
percent revenue tax.
“That is where we came up with
the approximate number of 30 percent.
Again, this would not provide
any profit, only cover our costs.”
What happens if nothing is done? “There will be a public health crisis
if private clinics drop out of vaccines
altogether, since private clinics vaccinate
85 percent of all children,” Dr.
Ferreris says.
The worse case scenario, he says, is
that if private clinics stop offering vaccines
to patients under their health
plans, because the pediatricians cannot
afford it, then there will be a barrier
to vaccines, resulting in a possible
public health crisis such as has
occurred in Puerto Rico, where private
physicians have stopped vaccinating
because of unfair compensation.
Medicine has made great strides
in controlling and eradicating serious
viral epidemics and bacterial
infections due to advances in immunizations
and large-scale vaccination
programs. If pediatricians stop offering
vaccines to their young patients,
then these advances could disappear
and be swallowed up in a wave of
disease and infection.
“It’s a sign of the times when we
cannot get something as simple and
vital as vaccines paid properly in
order to protect children and society
as a whole,” Dr. Ferreris says. “If
children aren’t vaccinated, then
adults will be at risk of acquiring
diseases from the children.”
Pamela Mooman is the editor of San
Antonio Medicine.
