Association of Maternal and Child Health Programs
Washington, DC 20036
February 27, 2002

The Honorable Nancy Johnson
Subcommittee on Health of the Committee on Ways and Means
United States House of Representative
Washington, DC 20515

Re: Committee Hearing on Medicare Physician Payments

Dear Representative Johnson:

The Association of Maternal and Child Health Programs (AMCHP) represents state public health leaders and others working to improve the health and well being of women, children and youth, including those with special health care needs, and families. We are very concerned about the Centers for Medicare & Medicaid Services' (CMS) decision to publish only the practice and physician liability expense values for the two vaccine administration codes (90471 and 90472), without publishing any values for the physician work involved in the administration of vaccines. As a result of this under -valuation, we fear that many Medicaid programs and other insurers that base payments on the Medicare fee schedule will reduce reimbursement for this service to levels well below the actual costs incurred by providers. Under-compensating private physicians for vaccine administration, thereby discouraging them from providing this valuable service in their offices, could have a significant detrimental impact on the viability of our nation's immunization efforts.

State health programs across the nation alongside federal partners CDC, HRSA, and CMS, and the private medical community have worked hard to reach the current high rate of immunization and low rate of vaccine-preventable diseases in the United States. The Vaccines for Children (VFC) program has been remarkably effective in moving vaccine delivery for low-income families into the setting of a medical home, where children receive the benefit of comprehensive health services as well as immunizations. This effort to increase vaccine availability and utilization by increasing family awareness and encouraging families to seek primary, preventive care supports national health status goals reflected in the Healthy People 2010 initiative. Now is a particularly inopportune time to weaken that system, as it is already being severely stressed. Shortages of varicella, measles, mumps, rubella, DtaP and pneumococcal vaccines mean providers must recall the child, thus, increasing their financial burden and workload. In some cases, physicians' offices vaccine shortages mean that patients seek immunizations in already overburdened public health clinics.

The rationale guiding CMS' values for vaccine administration does not reflect what actually happens at an administration site, since there is, in fact, physician work involved in the administration of childhood vaccines. The American Medical Association's Related Value Update Committee (RUC) recently reaffirmed their recommendation to include specific vaccine administration physician work values. At the time each dose is administered, the physician must explain the vaccine's benefits and possible adverse reactions to the patient's parents or guardians. Provision of this information is requirement of the National Childhood Vaccine Injury Act. With the increases in disseminating misinformation, the time that physicians spend on education and cognitive discussion has increased. Some children receive vaccines from a variety of sources (e.g., public health departments, community health centers) further complicating the physician's task of forming a comprehensive vaccine history using scattered records. Finally, physicians make every effort to avoid any "missed opportunities" to immunize a patient, so they administer vaccines in contexts other than preventive health care visits.

For these reasons, AMCHP strongly recommends that the committee correct this problem, either through working with the administration on rewriting the rule or through legislative action if necessary, so that physicians are adequately compensated for administering vaccines to our nation's children.

The goal of public health and its partner organizations is to foster a healthy society. This goal will be significantly and negatively affected if private physicians are not adequately compensated for administration of vaccines. The result would be increasing the burden on public health clinics and reducing the likelihood that a child will receive comprehensive care in a medical home. If CMS does not change the Medicare fee schedule for vaccine administration, the result could be a decrease in the number of immunized children and a concomitant increase in preventable -- and sometimes fatal -- infectious diseases. We urge the committee, on behalf of our nation's women, children, and their families, to address this issue as you look at the broader issues involved with the physician payment rule put forth by CMS.

Sincerely,

Deborah F. Dietrich
Acting Executive Director