Tuesday, September 29, 2015

Prescriptions for Flu Shots

We have started to get requests for pharmacists again this year to give flu vaccines to our patients.

THIS MAKES ME FURIOUS! (Can I be any more clear with this? I am not usually alarmist, but it really is frustrating.) Let me try to explain. I apologize in advance for complaining, but...


The pharmacy is essentially wanting to put the onus on me to verify that the child is healthy enough for the vaccine and doesn't have any contraindications. Of course this is getting very difficult to do even in my office now that walk in clinics are conveniently located everywhere, so continuity of care is lost. If I haven't seen the child in many months, I might not realize that he had a wheezing episode last week but went to another urgent care center to manage. The pharmacy wants me to spend the time looking at the child's chart to verify the health of the child without seeing the child, write the prescription, and have unused flu vaccine sitting in my office (or waiting to be shipped to my office) that I must pay for but not use. Really???

Cost of care

And all of this for free, since the patient is not coming to my office for a visit, but spending his money at the pharmacy. My time needs to be valued somehow in this. A lawyer would charge for the time spent, but I cannot get reimbursed for this. Pediatricians are famous for being nice and giving free advice and care.

Now don't get me wrong. I didn't go into pediatrics to get rich. Medical students who want to get rich don't go into primary care. But I do need to cover my costs and support my practice by earning income with patients who come into the office. Primary care offices are struggling to survive. Many are selling out to hospitals, which increases healthcare costs. 

Continuity of care in the medical home: special dosing for kids, live viruses, and chronic illness

Flu vaccines in kids, especially under 9 years of age, have different rules than older kids and adults. They must have two vaccines of the same strain once before getting a simple yearly booster. If we don't have proper documentation of previous flu vaccines, they need two doses. Until we have a nationwide vaccine database, the pharmacy is unlikely to have the complete vaccine record for these kids and if they give some of the vaccine, the primary care office might not have records of the vaccines.

Parents often don't remember which of their children have been vaccinated -- let alone the specific dates and which particular vaccines were given. If kids get live virus vaccines, they must be given at least 28 days apart from one another or on the same day. This can cause issues if a child gets the kindergarten vaccines at their doctor's office and then a FluMist at the pharmacy or other walk in center (or vice versa). It is easy to see how mom and dad might each take the child to one of the places and not realize the contraindication. If all vaccines are given in one location (or if a person transfers records to another physician for continuing care at a new location) then this type of mistake can be more likely avoided. I try to remember to warn parents to wait at least 28 days before giving the FluMist to their child at the well visit if they get the MMR and/or chickenpox vaccines around flu vaccine time, but sometimes I forget and parents often forget when the time comes at the pharmacy. These kids don't suffer from harm, but the vaccine is not effective and must be given again. I've seen more than one frustrated family suffering from this scenario...

Another issue with getting vaccines outside the medical home is when there is a chronic issue, such as asthma, and parents don't accurately remember the severity. Even in my office when I've talked to parents and given a written Asthma Action Plan, they sometimes tell my nurse the child doesn't have a history of asthma. The nurse can question further because it's in the chart. The pharmacist won't know to question in a different way, especially if the family hasn't filled medications for that child at that pharmacy.

Inventory issues

We have been ordering and giving flu vaccines for longer than the 16 seasons I have been a part of Pediatric Partners. Each year there has been some frustration with the flu vaccine season.

See here and here and here for some of our headaches -- I wasn't blogging at the time of the novel H1N1 outbreak, but you all remember that, I'm sure.

Now that some kids get vaccinated at the parent's workplace, others at pharmacies, and others not at all it is getting more and more difficult to predict how much flu vaccine to order. If we over order, we are stuck with vaccine that can't be used (in other words, we stand to lose a lot of money). If we under order, parents are upset that we run out. Some years we can get more, others we can't.

We offer flu vaccines in our office, or at least we do when we have the vaccine in our office. For the second year in a row we are experiencing shipping delays. This is frustrating because we love to take advantage of the school aged kids (especially college aged "kids") being in the office in late summer and getting the flu vaccine out of the way. We can't give it at well visits if we don't have it, so we must pay nurses for more overtime having more flu vaccine clinics when we finally get the vaccines in stock. It's much easier for all to get it at an already established visit, but we do not have control of when the vaccine arrives at our office.

Pharmacies giving vaccines is a relatively new thing. I am frustrated that they are getting their supplies before us and offering them to our patients before we even have a chance. We have more and more difficulty ordering flu vaccines because we have no idea how many kids will get them elsewhere versus our office. We must pre-order during the winter before the next season, often when we are still offering vaccine for the current season, so we don't know if we will run out early or have leftovers. That makes it really hard to predict use for the next season.

Prescription requests 

Thankfully when I get a faxed request for such a prescription, I have an easy answer: No.

Our malpractice carrier has advised us to not write prescriptions for over the counter medications unless we are seeing the child in person. We have interpreted vaccine prescriptions to be in a similar category. If we cannot assess how sick or well a child is, we should not make the decision for any medicine (or vaccine) to be given. If the pharmacist wants to do an evaluation and order it, great. Otherwise, we are more than happy to vaccinate our patients.

Another reason to get the vaccine at your doctor's office

I just saw in a Slate article that vaccines might be better covered by insurance by an in network provider: "Pediatrician Walter Orenstein of Emory University, who chairs the National Vaccine Advisory Committee and formerly was the country’s assistant surgeon general, notes that the Affordable Care Act now requires that insurers cover vaccines against flu and several other diseases with “no co-payments or other cost-sharing requirements,” but, again, the catch is “when those services are delivered by an in-network provider.”"

Getting the vaccine

Please be patient with us. It wasn't that long ago that it was recommended to hold off on giving flu vaccines until October, thinking that the vaccine wouldn't last the season if given too early. Now that we know it is okay to give it earlier, that doesn't mean we must give it earlier. It isn't even October yet and people are panicking that they won't be able to get the vaccine. As far as I know, there's plenty of vaccine. It just hasn't all shipped yet. We are getting small allotments and giving it to kids whenever possible if they're in the office when we have stock. Unfortunately we can't schedule any vaccine appointments yet because our stock is too limited and we might run out before that appointment. We will be getting more soon. When we have enough in stock to schedule flu vaccine clinics we will let our patients know.

We're not alone in this. Most pediatricians I've asked are in the same boat. Please be patient with us all.

Dr Mellick got a FluMist in a previous season

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