by Wanda Filer, Head of Medical Affairs, VaxCare

March 2020 – Measles, influenza, Hepatitis A and many other vaccine preventable disease stories fill the headlines today.

While we see a lot of coverage about the anti-vaccine movement, there are other under-appreciated barriers to increasing adult and pediatric vaccine rates occurring in many ambulatory care practices in the US. While pharmacy immunization has improved access for adults, it is not the full solution, as the actual rates of influenza vaccine uptake have remained flat over many years even with pharmacy participation.

Instead, disintermediating vaccines from the primary care medical home can lead to missed opportunities for patients. Often a patient presents to their primary care office for a vaccine and quietly shares other concerns that lead to critical services… suicidal thoughts, chest pain, family disruption, hunger. Vaccine delivery is not only a portal to better preventive services and healthier populations, it also can be an opportunity to identify other needs.

As a Family Physician and past president of the AAFP, I have been told by many of my colleagues that they are struggling mightily to afford vaccines, feel that they are losing money, and embarrassed that they cannot always continue these services for patients. Many now grudgingly send their patients to pharmacies or health departments, sadly aware that many of these patients do not follow through. This is not the kind of medicine they wish to practice…but the thin margin on vaccines leaves them with little choice.

Ambulatory care practices frequently struggle with the huge carrying costs of vaccines (typically tens of thousands of dollars), uneven and manual inventory management, time consuming staff documentation, loss and leakage of doses, and often dismal administration fees. A $200 vaccine dose may or may not get reimbursed at full cost and the practice is typically working solely for the administration fee to cover its costs. If a busy nurse puts the vial for room 2 into her pocket after administration (planning to enter the lot number and expiration date later for billing when she gets a chance) and gets distracted by the EKG in room 1, the ear cleaning in room 3, and the breathing treatment underway in room 4, the entire $2000 box will need to be administered before the practice can break even. Wasting one dose when a patient changes his mind or forgetting to enter it to collect the administration fee happens frequently in the manual, fragmented processes used by most busy offices. Financially, the margins are lost due to loss and leakage of doses. Worse, if the power goes out and the vaccine refrigerator fails, the entire investment in stored vaccines can be lost, a devastating scenario far too familiar for many in primary care.

Giving tools to these practices to efficiently manage the vaccine process is vital…to their patients, to the practice and to health of the community. Attempts to offset carrying costs in a handful of states via Universal Purchase, while laudable, have not delivered hoped-for results. New vaccines can be costly and state budgets have challenges as well. The problem is much more systemic than the cost of vaccine alone.

A full end-to-end technology-based solution for these primary care practices is in order.

Providing no cost vaccines to practices, automated restocking and inventory management, tech-enabled easy-to-use tools to document doses in the EHR and, where permitted, the state immunization registries, while also automating the billing for vaccines and administration fees, is now available in many states. Even some county health departments are using these solutions as a resource to protect valuable public health dollars. Holding the practice harmless for refrigerator failures and quickly restocking can keep the practices fully immunizing and protecting their patients. Instead of running out of flu vaccine doses in late winter and being unable to take the financial risk of ordering more doses late in the season, and having patients go unimmunized, practices can quickly obtain needed doses and return unused doses later.

If we are to strengthen primary care, a crucial national health policy priority, we must invest in it…not by pulling out needed services such as immunizations, but by providing 21st century solutions. Immunization delivery is one such opportunity and is critical to the health of the nation. With new infectious disease threats looming large, the time is NOW to strengthen immunization delivery in primary care and overcome these antiquated barriers.



About the Author

Wanda Filer, MD MBA FAAFP is the Head of Medical Affairs for VaxCare (Orlando,FL), using innovation to improve immunization rates in practices, public health and health systems. She served as first Physician General of Pennsylvania and President/Board Chair of the American Academy of Family Physicians (Leawood, KS). She resides in York, PA and sees patients at Family First Health, an FQHC. She serves on several Boards of Directors, both for profit and not for profit. She received her MD degree from Hahnemann University (Philadelphia) and completed her Family Medicine residency in New Jersey. She received her MBA from Pennsylvania State University.

One Response to “The Difficult Reality of Immunizations in Ambulatory Care”

  1. Andrea Morgan

    Really thoughtful and pragmatic approach. As the population ages then it will be important to remain vigilant with vaccines, documentation and ease of sharing the information as needed.


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