Is Gardasil worth a shot?

When Merck launched a multimillion-dollar marketing campaign last year to promote Gardasil, its new vaccine to prevent cervical cancer, company officials probably did not anticipate that its signature phrase -- “one less” -- would apply not just to malignancies but also to physicians. Yet that slogan has come to symbolize the response of doctors.

Pincered by rising costs and eroding reimbursements, and resentful of what they regard as a long-standing and unfair financial burden, some doctors, especially pediatricians and gynecologists who are most likely to be asked for the vaccine, are refusing to buy it or restricting who receives the shots.

Discontent over the price of the vaccine -- the most expensive ever approved -- highlights a long-simmering dispute over reimbursement for immunizations, traditionally regarded as bedrock medicine. It is a dispute, experts say, with significant public health implications that has accelerated as the number of costly new vaccines has proliferated.

“This is a national issue that is affecting lots of people,” said Benjamin Gitterman, president of the Washington, D.C., chapter of the American Academy of Pediatrics. “It’s a matter of cash flow,” Gitterman added. Some insurance companies are paying doctors $122 per shot -- just $2 more than the price physicians pay for a dose of Gardasil -- an amount not sufficient to cover the cost of stocking and administering the vaccine, doctors say. The problem is disproportionately affecting pediatricians, experts say, because they administer the majority of immunizations and are among the lowest-paid specialists.

“Some plans are saying I’ll give you $90 -- and not a penny more,” said Washington pediatrician Promise Ahlstrom.

Instead of routinely immunizing females between the ages of 9 and 26, the population for which the three-dose vaccine is approved, some doctors are handing patients a prescription to be filled at a pharmacy. Patients who do this, however, may be stuck with the tab: Many insurers, including CareFirst and Aetna, pay only for vaccines supplied by a doctor.

Other physicians are reserving Gardasil for patients whose insurers have agreed to pay what the doctor deems a “reasonable” fee -- usually a minimum of about $140. Still others are requiring upfront payment from patients.

Merck executives have said that the price of Gardasil is justified by its development costs and its value. Insurance company officials agree that the vaccine is expensive, but add that physicians are adequately compensated for providing it.

Many pediatricians see things differently.

“We shouldn’t be expected to subsidize the public health system and perform our jobs at a loss,” said Dr. Jon R. Almquist, chairman of the pediatrics academy task force on immunization, in a recent statement. “We’ve carried this burden long enough.”

Dr. Herschel R. Lessin, medical director of a large pediatric practice in Poughkeepsie, N.Y., that participates with 50 health plans, agrees.

“I have to pay for nursing time, supplies, syringes, alcohol pads, dropped doses and time to explain it,” Lessin said of the ancillary costs of providing vaccines. “And when insurance companies decide to pay me $122 per dose and take three months to pay, I can’t afford to do it. For insurance companies that are paying me $140 or $150 a dose, I’ll give it.” In other cases, Lessin said, he is giving patients a prescription to be filled at a pharmacy and administering the vaccine for a $25 fee.

His patients, Lessin said, “understand this.”

Christina Sprague of Washington said she has spent several hours on the phone in recent months trying to find a doctor who will immunize her daughter, who attends an out-of-state college.

“It’s been pretty frustrating,” Sprague said. “This should be straightforward.”

Linda Woolley, a lawyer who lives in the Washington area, said she called four doctors’ offices recently seeking one that had the vaccine, which officials at CareFirst BlueCross BlueShield told her was covered under her plan.

None did, but a doctor in the office of Woolley’s obstetrician-gynecologist, Mark Reiter, wrote a prescription and agreed to give the shot to Woolley’s teenage daughter. But after Woolley spent $181.99 for the first dose of the vaccine from CVS, CareFirst rejected the claim, saying it wasn’t covered because the vaccine had not been supplied by a physician.

Reiter said his practice, one of the city’s largest, doesn’t buy Gardasil because the $2 profit in the reimbursement rate quoted by insurance companies “isn’t worth it.”

Woolley sees her situation as a Catch-22: “I find it curious that states are mandating this” but consumers have trouble getting the vaccine.

CareFirst spokesman Jeff Valentine said the company has received several similar complaints from subscribers and is looking into them.

“We are in the process of examining our rates,” Valentine said, adding that several physicians have complained about low reimbursements. But he said that CareFirst, one of the largest insurers in the Washington area, is “competitive with what other insurers are paying,” although he declined to discuss fees. Recently Cigna and UnitedHealthcare announced they were raising reimbursement rates for Gardasil.

Walt Cherniak, a spokesman for Aetna, said the company pays doctors $120 plus a 5% markup -- $6 -- and an administrative fee of $8 to $15. In some cases doctors can also bill for the office visit, he said.

“We believe our reimbursement is reasonable and sufficient” to cover doctors’ costs, Cherniak said. “And we encourage members to ask physicians for the vaccine.”

The economics of providing vaccines has changed dramatically in the last two decades, said Dr. Anne Francis, an associate clinical professor of pediatrics at the University of Rochester School of Medicine in New York. Twenty years ago it cost $150 to fully immunize a child with nine vaccines, she said. The current cost is $1,500, and the number of vaccines has jumped to about 35. These days, she said, there is little room to recoup the cost of a dropped syringe of vaccine, a child who pulls away, a patient who changes her mind at the last minute or refrigerated doses that must be discarded after a power failure.

“If I was a single practitioner, I would need to come up with $36,000 just to buy (the full three doses) of Gardasil for 100 patients,” she said.

“That’s a lot of cash to put out,” Francis said, especially for small practices.

Some doctors say the benefits outweigh the problems.

“For the first six to 12 months (after a new vaccine is introduced), the insurance companies don’t know what they’re doing,” said Virginia pediatrician Gary Bergman. His large practice, he said, “probably breaks even” providing vaccines, which he regards as a core mission of pediatrics.

“Pediatricians are nickel-and-dimers,” Bergman said.

Officials at the American College of Obstetricians and Gynecologists say they are hearing about inadequate reimbursement from members who are reluctant to buy Gardasil.

“We need to make our members understand that [vaccines] are part of their practice,” said Gregory Moore, chairman of ACOG’s committee on gynecologic practice.

Moore attributes some of the resistance to his specialty’s lack of experience using vaccines.

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(BEGIN TEXT OF INFOBOX)

HPV vaccine facts

The HPV vaccine is given as a series of three shots over a six-month period. The second and third doses should be given two and six months (respectively) after the first dose.

Will the HPV vaccine be covered by insurance plans? Though some insurance companies may cover the vaccine, others may not. Most large plans usually cover the costs of recommended vaccines. However, there is often a short lag time after a vaccine is recommended before it is available and covered by health plans.

Will girls/women who have been vaccinated still need cervical cancer screening? Yes, for three reasons. First, the vaccine will not protect against all types of HPV that cause cervical cancer, so vaccinated women will still be at risk for some cancers.

Second, some women may not get all required doses of the vaccine (or they may not get them at the right times), so they may not get the vaccine’s full benefits.

Third, women may not get the full benefit of the vaccine if they receive it after they’ve already acquired one of the four types of HPV.

Should girls and women be screened before getting vaccinated? No. Girls and women do not need to get an HPV test or Pap test to determine whether they should get the vaccine.

An HPV test or a Pap test can tell that a woman may have HPV, but these tests cannot tell the specific HPV type(s) that a woman has. Even girls and women with one HPV type could get protection from the other HPV types they have not yet acquired.

-- Washington Post

Source: Centers for Disease Control and Prevention