AMERICAN-STATESMAN STAFF
Tuesday, June 26, 2007
Austin doctor Lisa Savage was thrilled when a human papillomavirus vaccine became available last summer. But since then, Savage, like many other doctors, has found she can’t afford to offer it to her patients.
“We were vaccinating people left and right, and all of the sudden, I’m looking at my business situation and going, ‘Aah, I can’t do this forever,’ ” said Savage, a gynecologist. “We made the very difficult decision not to stock it anymore, which just breaks my heart.”
Stocking and administering the vaccine, Gardasil, isn’t a problem for large health care providers because the sheer number of shots they give reduces their financial risk. And clinics for low-income patients offer it free through federal and state programs. But for solo practitioners and other small offices, which must pay out of pocket for the vaccine up front and scramble to get reimbursed later, missing a single payment can be devastating.
“We become the middle man between the pharmaceutical company and the patient,” Austin family practice doctor Ron Byrd said. “We’re supposed to purchase and supply this and hope that we can get reimbursed.”
Gardasil, which is designed to prevent cervical cancer-causing HPV, is not the only immunization that doctors say is financially difficult for them to stock. But at $360 for the three-shot series, Merck & Co.’s Gardasil, the only HPV vaccine on the market, is far more expensive than other vaccines.
Although the vaccine isn’t required — Gov. Rick Perry’s executive order mandating that girls receive the vaccine before sixth grade was shot down by the Legislature earlier this year — some clinics report steady demand. There is no FDA-approved HPV vaccine for boys.
The Austin Regional Clinic, which has about 200 primary care physicians, specialists and doctors who work at hospitals, does not have financial concerns about the vaccine, said chief operating officer Susan Patton.
But at a much smaller practice, Austin gynecologist Albert Gros said he doesn’t know how much longer he can continue to offer the vaccine. He said it’s an issue not only with vaccines but with products such as intrauterine contraceptive devices.
“Many of these the doctor has to stock at their own expense,” he said. “There’s really not a good system in effect.”
Savage, a solo practitioner who stocked Gardasil for nearly a year, said payments from insurance companies would trickle in weeks to months later, sometimes at her cost and sometimes below. Sometimes claims would be denied for legitimate reasons, but “sometimes it was a ridiculous denial. They’d say it was the wrong gender for a patient named Jill.”
Virtually all major health insurance companies are reimbursing doctors for Gardasil, said Jared Wolfe, executive director of the Texas Association of Health Plans.
“The vast majority of claims, when filed cleanly, are paid quickly and accurately and on time,” said Wolfe, referring to all types of claims.
But Byrd pointed out that even if an insurance company reimburses for Gardasil, that doesn’t mean it’s covered on every patient’s plan. And contracts with insurance companies generally prohibit doctors from charging a patient up front for a vaccine, he said.
“I say to the Merck representatives, ‘Why don’t you just give me the vaccine, and when I get reimbursed, I’ll pay you?’ ” Byrd said. “They say, ‘Oh, no, you’ve got to pay for it up front.’ ”
A Merck spokesman could not be reached for comment.
Austin gynecologist Lisa Jukes said she encourages patients ages 9 to 26 to get the vaccine. But she doesn’t offer it at her office because she can’t afford the overhead cost, she said.
“I think it’ll always be hard for small practices to cover it,” Jukes said.
Instead, she writes a prescription for the immunization and sends her patients to the pharmacy at H-E-B. Twenty-nine H-E-B pharmacies in the Austin area administer Gardasil by appointment, said H-E-B spokeswoman Jill Reynolds. Patients pay cash up front — $525 — and work with their insurance companies on reimbursement, Reynolds said.
But HPV is not widely available at pharmacies, Byrd said. Walgreens, for example, does not offer the HPV vaccine at all in the Austin area, said company spokeswoman Carol Hively.
Byrd said that since he stopped offering the vaccine two months ago, he’s been sending patients to Passport Health, a vaccine provider whose Austin location is one of 130 nationwide. Passport charges $540 for the three-shot series in Austin, said spokesman Jorge Castillo.
Uninsured children or those enrolled in Medicaid or the Children’s Health Insurance Program can receive free vaccines from the Vaccines for Children Program. The free shots are available at many Austin-area locations, including the Shots for Tots program at the St. John Community Center, the Rosewood-Zaragosa Neighborhood Center and the Far South Health Clinic.
Dr. Susan Strate of the Texas Medical Association is part of a team of doctors that has been meeting regularly with representatives of health plans.
“The bottom line is that physicians want to see immunizations given,” said Strate, a Wichita Falls pathologist. On payment issues, she said, “we still have a ways to go.”
Prices of vaccines
Of the vaccines recommended for children up to 18 years old, HPV is the most expensive.
HPV $360
DTaP (diphtheria, pertussis, tetanus) $107-$110
TDaP booster (tetanus, diphtheria, pertussis) $36
Polio $91-$105
Hepatitis B $64-$70
Hib (Haemophilus Influenzae Type B) $87-91
Pneumococcal (pneumonia, meningitis) $295
Hepatitis A $58-61
Measles, mumps, rubella $90
Meningococcal conjugate $89
Chicken pox $150
Rotavirus $201
Influenza $12-18
Price includes all doses in series, except influenza, which is recommended annually.
Sources: Centers for Disease Control and Prevention, Texas Department of State Health Services
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