Further reflections on the recent influenza epidemic

February 2004

Since the publication of our last article, we received several letters by e-mail about the challenge of instituting pay for service for influenza vaccine or rapid tests. It seems that many pediatricians would like to initiate a similar policy but fear legal action because they are deviating from their signed contract with the major medical insurance companies.

Perhaps it requires a few pathfinder pediatric practices to demonstrate the soundness and safety of this approach. There are few losers in this scheme. The children win because more of them receive timely and important immunization against influenza virus. The physicians win because they can turn a profit from what had been an annual loss for providing an important service. The parents win because they also receive immunization for a nominal cost during a scheduled visit for their children.

The insurance companies win because they save many thousands of dollars in reimbursement costs as well as the cost of defending their oftentimes-insufficient payments for the administration of the vaccine.

In preparation for the 2004 influenza season, our office manager pre-ordered 400 doses of injectable influenza vaccine in January 2003. Ordering bulk influenza vaccine 10 months prior to actual receipt of supplies saves us about 3% to 5% on vaccine costs.

In late September 2003, nurses and pediatricians actively and enthusiastically recommended the flu vaccine. We offered to give the vaccine to children at least 6 months old as well as any adult.

As noted previously, our present policy for receipt of influenza vaccine is payment of $20 at the time of service.

Children without medical insurance and those on Medicaid received the vaccine without charge under the Vaccine for Children Act. We do not bill any of our managed care companies for influenza immunizations. Our policy is to return any money received from managed care companies when our patients have not honored their signed commitment, not to submit the $20 cost of the vaccine for reimbursement from managed care companies.

Although we took a calculated risk in charging our patients for the influenza vaccine rather than billing the medical insurance companies, we carefully prepared a signed consent contract that clearly spelled out the terms of providing influenza vaccine in our office.

In early January, we received a nasty telephone call from a customer representative from a major medical insurance company who called to inform us that we were charging patients for the flu vaccine in violation of our contract with the company.

The company representative stated that we were entitled to receive only $4.75 from the company plus the customary $10 co-pay from the patient at the time the vaccine was administered.

As we all know, the co-pay is only valid if the child receives the vaccine without any concomitant service such as an office visit for illness or wellness.

After being threatened with a letter of reprimand to be placed in our practice file with the insurance company, we contacted the company’s medical director and faxed a letter of explanation, a photocopy of the first article that was published about our practice’s experience with influenza immunization, and a copy of our patient consent form.

About one week later, much to our surprise and delight, the medical director called me and said that he read all of the material that we faxed to him.

He said that as a physician he would do his best to support us in the event that the issue became litigious. Will wonders never cease?

As of Jan. 7, 2004, there have been no more complaints and since we depleted our supply of killed injectable influenza vaccine before Christmas, we may have successfully reached our goal of a small profit for flu vaccines.

By the end of December 2003, 37% (n = 51,300) of the eligible children in our pediatric practice were immunized.

At the peak of influenza virus, we switched to FluMist, the live cold-adapted intranasal vaccine for children at least 5-years old, for which we charged $65.00.

We also insisted on signed informed consent for this vaccine. We initially ordered 100 doses and quickly found willing parents who were happy to pay the additional charges.

At least 2.3% (n=30) of the children (23/1000) who had received influenza vaccine 10 or more days prior to developing upper respiratory symptoms were diagnosed with influenza using a CLIA-waived rapid test for influenza A/B (QuickVue, Quidel Corporation).

The results-while-you-wait test was offered without charge to children who had influenza symptoms for less than 48-hours, including a temperature of at least 37.2 C. Forty-nine percent (49%) of the 237 nasal wash specimens were positive for influenza A/B.

By the third week of December, we depleted our supply of rapid tests for influenza. We were fortunate in procuring an additional 100 tests from one manufacturer, however, it was very difficult to replenish our supply of rapid tests.

Although the philosophy in some busy pediatric practices is to discourage parents from bringing their children to the office for fever and upper respiratory symptoms during an influenza epidemic, we believe that treatment in the first 48 to 60 hours makes a dramatic difference in resolution of signs and symptoms of influenza.

Children who receive anti-influenza medicine had to have a positive rapid test for influenza, at least until our supply of rapid tests were depleted.

Our practice treated children older than 1 year with anti-influenza drugs, usually amantadine, (5 mg/kg/day in two divided doses for five days).

One of the associate pediatricians preferred to prescribe oseltamivir (Tamiflu, Roche) instead of amantidine. During the height of influenza season, most of the area drug store chains intermittently depleted their supply of oseltamivir.

It has been shown that prompt treatment with an appropriate anti-influenza drug reduces signs, symptoms, and contiguousness of influenza.

Confirmation of influenza A virus by culture at a reference laboratory was greater than 90% of the first 150 specimens submitted.

Approximately 2,240 children in our pediatric practice did not receive influenza vaccine. Of these, 86 children were diagnosed with influenza disease. The influenza rate of the non-immunized group was 3.8% or 38/1000.

We continue to hope that the complaints to managed care companies from parents are few and tepid. Please let us know your thoughts about this idea.