Physician perceptions a major barrier to adult vaccination

The obstacles to adult vaccination have been well-documented, but a new study reveals that overcoming physician perceptions about vaccines may be the biggest hurdle of all.

The report, published in Human Vaccines and Immunotherapeutics, sought to identify what keeps physicians from recommending and administer vaccines to adults by polling physician practices about their perceived barrier to adult vaccination. Specifically, the study investigated recommendations for influenza, tetanus, diphtheria, pertussis, and zoster vaccinations with a focus on what type of recommendations were made to patients with Medicare versus commercial insurance plans.

Most physicians polled were on board with the need for adult vaccination, with 76 percent agreeing that too many adults are suffering from vaccine-preventable diseases and 74 percent agreeing that adult vaccines aren’t being used as often as they should. While most physicians—91 percent—noted in the survey that influenza vaccines were very important, those numbers dropped with other vaccines, with just 66 percent of physicians considering the zoster vaccine very important.

Rates of vaccine recommendations were fairly even for influenza, at 84 percent to Medicare patients compared to 82 percent for commercial plan patients. Administration rates were similar, with 80 percent of Medicare patients administered the vaccine by their clinicians, and 78 percent of commercial plan patients. Referrals were made to 11 percent of patients in both groups, according to the report.

Tdap recommendations made to patients with commercial insurance plans were higher than for patients with Medicare, but zoster recommendations were made more often among patients with Medicare than commercial patients, according to the report.

More than 40 percent of physicians noted in the study that they would be “much more likely” to administer Tdap and zoster vaccines if they were covered under Medicare Part D, calling the financial barriers a “major” problem for these patients compared to patients with commercial insurance plans. The survey noted that physicians also were less likely to stock Tdap and zoster vaccines, mainly due to cost, but also preferred to administer these vaccines in their practice rather than refer a patient out.

Sean Clements, head of U.S. Vaccine Communications at GSK, said the survey findings are consistent with earlier studies that show physician knowledge, attitudes, and preferences influence their decisions about whether or not to recommend vaccinations to adult patients. The study also shows that cost, lack of tracking systems, and competing demands are all barriers that affect access to immunizations for adults, he says.

“A primary goal of the present paper was to highlight physicians’ perception and use of adult vaccinations in practice, with focus on examining whether there are differences between patients with Medicare coverage versus patients with commercial insurance coverage,” Clements said. “Our survey revealed differences in physician knowledge, practices—recommendation, administration, and referral, and perceived barriers for vaccines by insurance type, as well as gaps in physicians’ knowledge relating to patient eligibility for some vaccinations, vaccine insurance coverage and co-payments.”

The financial burden—related to the high cost of acquiring and storing vaccines—was cited as an obstacle to adult vaccination programs, Clements said, as well as failure to assess vaccination status during visits. Co-pays are also a hurdle, especially for Tdap and zoster vaccines for Medicare Part D patients.

“Policy changes that could help reduce the patient out-of-pocket cost and improve practice reimbursement for vaccine purchase and administration may reduce some of the barriers to adult vaccination, particularly for the more expensive vaccines with Medicare patients,” Clements said.

Changes to California’s Knox-Keene Act Potentially Impact California Health Care Providers

On July 1, a new regulation from California’s Department of Managed Health Care (DMHC) will go into effect, and will require health care providers that engage in global risk arrangements to apply for a license or exemption from the DHMC.

What is California’s Knox-Keene Act?

California’s Knox-Keene Act requires California managed care plans to obtain a license from the DMHC. The Knox-Keene Act requires licenses for “full service health plans,” which are entities that arrange for the provision of health care services to enrollees in return for a prepaid or periodic charge.

Historically, the DMHC also regulated “limited” or “restricted” Knox-Keene plans, which are entities that accept capitated payments from a fully-licensed Knox-Keene plan, and arranged for the provision of health care services to the plan’s members, but do not engage in marketing or individual enrollment activities. The requirements for obtaining a limited Knox-Keene license were not clearly established in the Knox-Keene Act or its implementing regulations, and the DMHC clarified these requirements in the new regulations.

The DMHC also monitors the activities of risk-bearing organizations, which are professional medical organizations that contract with fully-licensed Knox-Keene plans on a capitated basis for professional services, and engage in certain claims processing activities on behalf of the plan.

Changes as of July 1st, 2019

As of July 1, an entity that assumes “global risk” must obtain a license to operate a health care service plan, or apply for an exemption. The DMHC defines “global risk” as the acceptance of a prepaid or periodic charge from or on behalf of enrollees in return for the assumption of both professional and institutional risk. Professional risk is defined to include the cost of providing licensed professional services to a plan member, while institutional risk means the cost associated with providing hospital services.

The DMHC issued further guidance on the new regulations, which clarifies that the following arrangements between licensed plans, hospitals, and provider groups do not need to apply for a license or exemption: bundled payments, case rates, diagnosis-related group payments, contracts for professional services provided by a hospital emergency department, certain per diem payment arrangements, and certain arrangements where a provider is only assuming financial responsibility for professional services that may be provided in a hospital facility but the provider does not share in any hospital savings or losses. Providers also do not need to apply for a license or exemption for participating in an Accountable Care Organization arrangement, or for risk sharing arrangements with insurers licensed by the California Department of Insurance.

In recent years, many health care providers have entered into value-based or risk pool arrangements, where part of the payments they are eligible for are based on professional and institutional risk. Under the new regulations, these types of arrangements could be considered “global risk” arrangements that obligate the health care provider to obtain a health care service plan license or exemption from the DMHC. Health care providers may request a license exemption for a particular arrangement by filing financial forms, copies of the global risk agreement, and other documents as required by the DMHC.

The new regulation applies to global risk contracts that are issued, amended, or renewed on or after July 1, 2019. The DMHC will adopt a “phase-in” approach from July 1, 2019 through June 30, 2020, where exemption requests will be automatically granted if the requestor follows the DMHC’s “expedited exemption” process. This phased approach offers some immediate relief to health care providers entering into these arrangements. California health care providers will need to continuously evaluate whether their risk sharing arrangements implicate the new requirements, and may need to file exemption applications with the DMHC for their risk sharing arrangements.

Patient Access to Medical Services Varies by Individual Physician’s Will to Fight Insurance Companies

American healthcare reform debates are focused on strategies to provide “access” to medical services for all. Lack of insurance (or under-insurance) seems to be theprimary focus, as it is falsely assumed that coverage provides access. Unfortunately, the situation is far more complicated.

Once a person has health insurance, there is no guarantee that they will receive the medical services that they need. Not because their plan is insufficiently robust, but because the roadblocks for approval of services (provided in the plans) are so onerous that those providing the service often give up before they receive insurance authorization. In my experience, whether or not the patient gets the service, test or procedure that they require often depends on the individual will and determination of their physician. And that’s something we need to talk about.

Take for example, admission to an inpatient rehabilitation facility. Brain-injured patients aren’t much different than those with broken bones. We all know that bones need to be set (or surgically repaired) right away so that they will heal correctly. The brain is very similar – once injured, it needs to be rehabilitated in an intensive, multi-disciplinary environment at the earliest chance for it to achieve its best healing. Nevertheless, insurance companies regularly deny brain injury rehab to patients in the critical healing time frame. They will approve nursing home care for them, but not the intensive cognitive rehabilitation that they need, unless the rehab physician fights an epic authorization battle that can take 10 days or more to overturn the denial of services!  Imagine if your orthopedist had to beg, lobby, and testify for 10 days to fix your broken hip (while the insurance company simply approved you go to a nursing home)? Would he or she be willing to do this? What would happen to your hip in the mean time?

The “prior authorization” process for imaging studies and non-formulary medications is also designed to wear down the providers and passively deny services to patients, thereby saving costs for the insurers. Patients don’t realize that getting an MRI might mean an hour of automated phone system “hell” for their physician, waiting to speak to an insurance customer service rep with an algorithm that determines whether or not the patient is eligible for the service – unrelated to the physician’s judgment or the particulars of the patient case. In the average American primary care practice, an estimated 20 hours per week is spent by physician and staff, attempting to secure insurance approval for necessary tests and medications.  Will your physician have the endurance to prevail? That might be the difference in diagnosing your cancer early or not.

“Oh,” but the insurance companies say, “we had to put these bumps in the road to prevent over-testing and abuse of the system.” I agree that there are some bad actors who should be identified and stopped. Think of the phony durable medical equipment providers, bilking Medicare and private insurers by prescribing unnecessary and expensive wheelchairs, scooters, and other devices. These bad apples are rare, but because of them – all the “good guys” are being hen-pecked to death just to get a walker for a patient with multiple sclerosis.

Unfortunately, there is no incentive for the private insurers to lift the pre-authorization burdens from the “good guy” physicians. Therefore, this will probably have to be achieved through legislation. With big data, it should be fairly easy to identify extreme provider outliers – and have their practices reviewed. For the rest of us, our pattern of judicious prescription of tests, services, and procedures should win us a break from the daily grind of begging, wheedling, and cajoling payers to allow us to get our individual patients what they need, every single time we order something. Until this freedom to practice medicine is achieved, true access to healthcare will not simply be a matter of having health insurance, it will be whether or not your physician has the will to fight for your needs. A “good doctor” has to be more than an excellent diagnostician these days – she must be a savvy, health insurance regulatory navigator and relentless patient advocate.  Keep that in mind as you choose your next physician!

vWhy Medicine?

When I was applying to med school some 20 years ago in the UK, I was advised not to say at the interview: “I want to be a doctor because I want to help people.”

The answer was considered too dull back then. And in any case, I was asked “Why medicine?” only once.

“I’m not sure, but it’s not because my parents forced me.” I hesitatingly answered.

The interview panel giggled at my honesty, and for breaking a stereotype about Indians. I was accepted. But I doubt that this answer would cut it today.

Showing a sense of altruism is practically mandatory today for would-be doctors – one wonders if functional MRI will soon be used to prove empathy. But when I was 17 (the age when we typically applied to study medicine) that wasn’t the case. My curriculum vitae had little evidence that I wanted to help people.

There was no summer volunteering in eye camps in India. No travels to Africa to be indignant about poverty. The closest thing I had done that had any semblance of medicine was a brief stint as a hospital porter to supplement my pocket money: I carried blood vials from the emergency department to the laboratory. And although I waxed lyrical about the experience in my personal statement, I can’t say it was terribly inspiring to stare at cylinders of blood.

I do not recall caring for an ill acquaintance before I became a doctor. I didn’t go out of my way to help blind men cross the road. I didn’t routinely help old women pack their groceries—I still don’t. The most altruistic thing I had ever done was rescue a budgie when I was seven. I did not put that down in my personal statement.

My father, a physician, had little influence. I hardly saw him because of his work, and when I did he hardly spoke about work. I do remember, though, as a child, that he had a full skeleton of human bones in his study. My friends and I would concoct stories that it belonged to a former serial killer.

I watched no medical dramas. There were no medical personalities I admired. I never visited a hospital to shadow a doctor. And although I did fall ill with suspected appendicitis (which turned out to be mesenteric adenitis), it was hardly a life-changing experience.

Some contend that kids do medicine because of the job security and pay. To be honest, at 17, I thought I was immortal and couldn’t have cared less about security. As for money, well I was pretty left-wing.

The reality is that there is no inspiring story I can recount about why I became a physician. If it was a calling, then I didn’t hear it. I don’t think I was the only one in my medical school with the same experience. Over the years I have seen my classmates enjoy and endure medicine. Many are now excellent physicians with impeccable work ethics and compassion. If, back when they were students, they knew that volunteering in Chad during the summer break earned five points, they would have done it just for the five points. But what would it have proven?

Understanding what truly motivates someone to choose medicine, and whether that choice is motivated by noble inclinations or not is a forlorn endeavor. As soon as “I want to help people” becomes objectified as just another criterion for medical school admissions, as it has been, it will be gamed.

I’ve seen an entire generation of medical students become excellent doctors, even though, for them, “wanting to help people” was incidental to simply wanting to be doctors. The best I can garner about why I became a doctor is that it seemed like a good idea at the time. I’m glad I did, though – I have never experienced a dull moment in this profession.

Hello world!

Welcome to WordPress. This is your first post. Edit or delete it, then start writing!