Physicians are paid less to give combination vaccines

Medical practices generally earn less giving a single shot that protects against five diseases than injecting component immunizations separately, even though the same amount of counseling time is often required for combination shots as single vaccinations, according to a study.

Lower payment for administering combination vaccines is problematic because these shots are considered particularly important as part of an increasingly crowded childhood immunization schedule but may lead to financial losses for medical practices.

"Payers need to understand that physicians need to be paid appropriately for immunization administration," said Margie C. Andreae, MD, clinical professor of pediatrics at the University of Michigan. "We still have a significant number of practices that are essentially disincentivized to adopt the combination products."

The immunization administration codes 90465 and 90466 were replaced with 90460 and 90461 as of Jan. 1, 2011. The new codes allow physicians to bill for administration per vaccine component rather than per injection, although they can sometimes be tricky to use and are not allowed in all situations.

Dr. Andreae co-wrote a study published Nov. 21, 2011, in Pediatrics looking at data on 110,040 claims from a subscription billing service used by private practices from June 2007 to July 2009. Researchers found that, on average, physicians received $96.27 per dose from commercial payers to administer Pediarix to children younger than 2. This shot is composed of immunizations against diphtheria, tetanus, pertussis, hepatitis B and poliomyelitis. When giving the equivalent component vaccines -- DTaP, HepB and IPV -- medical practices earned $119.21, or $22.94 more (link).

This was primarily because, although the payment for the shots was comparable, practices could bill for the administration of three injections when using the equivalent component vaccines rather than only one when using the combination jab. Researchers say, however, that providing a combination shot can be just as much work for a physician.

"Physicians still have to spend the same amount of time counseling and sometimes even more for the combination vaccines discussing each of the different components," Dr. Andreae said.

For children on Medicaid, physicians were given $11.16 to provide Pediarix and $24.58 to give these immunizations separately, or $13.42 less. Payments are so much lower for Medicaid children than for those with commercial insurance because the shots are provided at no charge for this population through the Centers for Disease Control and Prevention's Vaccines for Children Program. Physicians bill for only an administration fee.