Rhode Island to distribute adult flu vaccine free to doctors

Washington -- Rhode Island legislators took up the cause of adult influenza immunization, and state physicians are optimistic that the resulting program will help smooth some of the rough spots in the ordering and delivery of vaccine.

A new law, signed in July 2006, requires the state health department to purchase vaccine and distribute it for free to physicians who enroll in the Immunize For Life program. Voluntary registration has just started, and the program will begin in earnest with the coming flu season.

Rhode Island is the first state to try this approach, said Annemarie Beardsworth, the program coordinator. "Other states are watching what we are doing."

It's one of many efforts proposed by state legislators around the country to help fix the nation's creaky flu vaccine system. Whether such measures will result in improvements is a matter of debate.

The various approaches were discussed at the National Influenza Vaccine Summit, which is co-sponsored by the AMA and the Centers for Disease Control and Prevention and was held April 18-20 in Atlanta. The summit brings together many stakeholders in the flu vaccine world -- from manufacturers and distributors to physician groups and payers.

More than 90 legislative measures have been introduced or passed recently in 35 states, said Andrew E. Van Ostrand, vice president of policy and research at the Health Industry Distributors Assn., a trade association based in Alexandria, Va.

Among the bills are those that require priority distribution of vaccine to doctors and public health entities, increased reporting requirements for distributors and manufacturers, and elimination or reduction of the preservative thimerosal in vaccine. Seven states already have enacted such laws. And there are measures that could result in programs like Rhode Island's that call on states to purchase vaccine in bulk and distribute it.

The Rhode Island Medical Society and the Rhode Island Academy of Family Physicians helped to draft the measure and lobbied for its passage. "We loved that bill," said Steven DeToy, the state medical society's director of government and public affairs. "We have had a similar pediatric vaccination plan for years, and we thought, since we already have a good way to do it for peds, why don't we try it for adults?"

He noted that he hadn't heard anything negative about the new approach since it was first proposed about a year ago. "It was almost a no-brainer."

Each year Rhode Island physicians had found it harder and harder to get vaccine, said Michael Fine, MD, physician-in-chief of Family and Community Medicine at Rhode Island and Miriam Hospitals in Providence. "They were getting frustrated and were giving up, so people weren't getting vaccinated as much."

Physicians believed that pharmacies and supermarkets received their supplies before the doctors, Dr. Fine said. This is a scenario that is reported by doctors around the nation, but one that is contested by distributors and others.

The new system will ensure that there is at least an ample supply of vaccine as "opposed to the physicians fighting it out with each other," DeToy said. "The program puts market clout back to the state, and it can help coordinate appropriate distribution to physicians."

The Rhode Island plan at least will eliminate the perception that some in the state are getting vaccine before others, said Andrew C. Eisenberg, MD, a family physician in Madisonville, Texas. Dr. Eisenberg represented the American Academy of Family Physicians and the Texas Medical Assn. at the summit.

A model for some

Such a system could serve as a model for other small states such as Vermont or Delaware, but large states like Texas would find such an approach more difficult, Dr. Eisenberg said.

Rhode Island's population, at just over a million people, equals the population of just one Texas city, Dallas. And all other facets of a plan would need to be magnified as well, he said. There are more insurers to negotiate with -- the Rhode Island plan calls for insurers to cover the cost of the vaccine. Texas also leads the nation in the number of uninsured children, Dr. Eisenberg said, and there are likely more languages spoken and greater ethnic diversity.

Although the nation's smallest state may be able to provide some stability to what can be a chaotic process, other legislative proposals, some argue, might make a bad situation worse by adding complexities.

For example, Van Ostrand sees laws that prioritize vaccine for physicians as being particularly problematic. Since most physicians already receive their vaccine from a distributor rather than a manufacturer, distributors would be faced with prioritizing among their physician customers. How could they decide whether physician A's patients are needier than physician B's patients?

"There seems to be this sense in the marketplace that manufacturers and distributors are making CVS, Wal-Mart decisions versus that of a small physician practice, whereas the reality is that it is much more complicated than that," he said.

Most physicians probably don't realize just how complex the vaccine production process is, Dr. Eisenberg said.

The vaccine changes yearly, the Food and Drug Administration must approve each step of the production process, and the process itself is outdated, dependent on a robust supply of billions of eggs to grow the flu strains. In addition, the three strains that are eventually combined into a single vaccine sometimes grow at different rates.

"So it's much more complicated than you make a widget and then you send your widget out to the people who ordered it," Dr. Eisenberg said.