Why VaccineViewSM?

Bringing transparency to the vaccine reimbursement process.

Inspired by PayerView^®, athenahealth's ground-breaking annual analysis of payer performance, VaccineView looks at vaccine reimbursement to pediatricians from a distribution of payers across the nation. The objective of VaccineView is to bring transparency to vaccine reimbursement where it is otherwise lacking.

A child receiving a shot from the family physician is a time-honored image in health care. Part of virtually everyone's experience in the US, it evokes the kind of health maintenance we expect from our physicians. Unfortunately, low and inconsistent vaccine reimbursement is creating financial difficulties for pediatricians and GPs who serve children and public health.

In addition to shouldering the direct costs for vaccines, physicians must also deal with indirect costs that include:

• Personnel costs for ordering and inventory
• Storage costs
• Insurance against loss of the vaccine
• Recovery of costs attributable to inventory shrinkage, wastage, and nonpayment
• Lost opportunity costs

The VaccineView analysis found that when the estimated minimum indirect costs of providing vaccinations are factored in, vaccine reimbursements are very often below physicians' total costs.

Given that vaccinations represent a substantial portion of pediatricians' out-of-pocket expenses, this underpayment threatens to compromise the financial viability of pediatric practices, which could in turn have an impact on public health.

Results

Pediatricians and GPs are often being insufficiently reimbursed for the cost of providing vaccines.

The AAP has found that when direct and indirect expenses for providing vaccines are totaled, they add up to between 17 and 28% above the vaccine price. For VaccineView, athenahealth has chosen to use the AAP's findings as a lens through which to examine vaccine reimbursement against total costs to the provider. Like the AAP, athenahealth used the CDC-published direct cost of vaccines.

After analyzing all the data, athenahealth found that 47.2% of vaccine reimbursements were below the AAP's CDC-published direct cost + 17% minimum, and 78.7% of reimbursements were below AAP's CDC-published direct cost + 28% maximum. athenahealth focused its analysis on the "cost+17%" figure, which was considered an accurate and fair "pulse-check" on the market. For example, if a vaccine's CDC cost was $100 with the AAP estimated indirect costs totaling at least $17, reimbursement was found to be less than the $117 total cost 47.2% of the time. This data supports the AAP's contention that when the total cost of vaccines are taken into account, a significant number of pediatricians are being underpaid for providing vaccinations, putting a financial burden on them.

VaccineView statistics also demonstrate that large practices appear to have more bargaining power and are generally able to secure a higher rate for the cost of vaccines. The data shows that small- and medium-sized practices were more likely to be reimbursed below cost + 17% than larger practices.

Methodology

Measurement is the first step to improvement.

VaccineView looks at the trends in vaccine reimbursement to pediatricians from a distribution of payers across the nation.

By tapping the unique data available through our cloud-based provider network, we were able to analyze payments for 158,983 individual charges lines from 1,427 physicians, billed to 48 payers. Eight vaccines were included in our analysis, vaccines for which we were able to obtain consistent price data and that are required or recommended in most states. We removed state-supplied vaccines with a state-supplied modifier and an allowable of less than $5.

In our analysis, we reviewed only vaccine codes, not vaccine administration codes. Vaccine administration is a separate expense, outside the scope of our analysis, which athenahealth believes ought to be covered separately.

To approximate direct cost, we compared a payment's amount to the lowest CDC-published direct cost in any given month. Vaccine manufacturers report this cost to the CDC, and it represents the undiscounted purchase price for vaccines.

To approximate indirect costs, we compared the same allowed amount to the AAP's total vaccine cost estimate of 17%-28% over CDC-published direct costs. We defined allowable amount as payments plus transfers—the amount the provider is allowed to collect, accounting for patients with deductibles, coinsurance, etc.—and used the most frequently occurring allowed amount for each medical group, payer, and month.

A medical group was considered below the acquisition cost of a vaccine only if their allowable cost was at least 1% below that cost. A medical group was considered below the acquisition cost plus 17% only if their allowable cost was at least 1% below that cost.