While public health experts agree that combination vaccines are an important tool for getting more children immunized against preventable diseases, physicians who administer those combination products are likely to be paid less, according to a study published online on November 21 and in the December issue of Pediatrics.
On average, physicians who used the combination vaccine Pediarix were paid $23 less by commercial health plans and $13 less from state Medicaid plans, compared with what they would have received if they had individually administered the components of the Pediarix vaccine – diphtheria, tetanus, acellular pertussis, hepatitis B, and inactivated poliovirus vaccines, according to Angela K. Shen, Sc.D., of the National Vaccine Program Office, Department of Health and Human Services, Washington, and her associates (Pediatrics 2011;128:1087-93).
The discrepancy isn’t due to the payment for the vaccines themselves, but in what physicians receive for their work and practice expenses under the immunization administration codes, said study coauthor Dr. Margie C. Andreae, professor of pediatrics at the University of Michigan, Ann Arbor.
"The difference in the payment for combination vaccines versus individual vaccines is really related to the physician work and counseling," she said.
Researchers from the University of Michigan; George Washington University in Washington; SDI Health in Plymouth Meeting, Pa.; the American Academy of Pediatrics; and the National Vaccine Program Office analyzed 110,040 vaccine claims, with 56,503 in the Pediarix arm and 53,537 in the equivalent component vaccine arm.
The claims were captured from SDI Health’s subscription remittance billing service, which is available to private practice office-based physicians. The study sample included claims from June 2007 to July 2009 for patients under age 2 years.
The researchers concluded that the lower payments were a barrier to the use of combination products.
However, Dr. Andreae said many physicians will be able to benefit from a recent payment policy change aimed at making vaccine payments equivalent regardless of whether the vaccine components are administered individually or in combination. In January 2011, the age-specific CPT codes 90465, 90466, 90467, and 90468 were replaced with two new codes – 90460 and 90461 – that pay physicians for the counseling work they do for each component of the vaccine.
According to an American Academy of Pediatrics document explaining how the new codes work, "code 90460 is reported once for the first component of each vaccine or toxoid administered by any route. The reporting of code 90460 includes counseling for the first vaccine component. Code 90461 is additionally reported for the counseling associated with each additional component of any combination vaccine or toxoid."
"The code was designed to recognize the physician work inherent in combination vaccines," Dr. Andreae said in an interview.
While the codes have been widely recognized by commercial payers, so far the Medicaid program is not paying physicians based on the new codes, she said.
Dr. Andreae said she hopes that the new codes will help practices that deal primarily with commercial payers, but the researchers haven’t analyzed the impact of the payment change.
One of the study authors is employed by SDI Health, which has periodic consulting arrangements with vaccine manufacturers mentioned in the study. Dr. Andreae said she had no relevant financial disclosures. This study was conducted under contract with SDI Health to the National Vaccine Program Office.