Inadequate reimbursement from insurance companies for Merck's human papillomavirus vaccine Gardasil is leading some physicians to refuse to purchase the vaccine and restricting the recipients to those whose insurers have agreed to pay a "reasonable" fee, the Washington Post reports (Boodman, Washington Post, 5/1).

Gardasil in clinical trials has been shown to be 100% effective in preventing infection with strains 16 and 18, which together cause about 70% of cervical cancer cases, and about 99% effective in preventing HPV strains 6 and 11, which together with strains 16 and 18 cause about 90% of genital wart cases, among women not already infected with these strains. FDA in July 2006 approved Gardasil for sale and marketing to girls and women ages nine to 26, and CDC's Advisory Committee on Immunization Practices later that month voted unanimously to recommend that girls ages 11 and 12 receive the vaccine (Kaiser Daily Women's Health Policy Report, 4/18). The vaccine is given in a three-shot series (Kaiser Daily Women's Health Policy Report, 1/23).

According to the Post, some insurance companies are paying physicians $122 per shot, which is only $2 more than the price doctors pay for one dose of Gardasil -- an amount that does not cover the cost of stocking and administering the vaccine, some doctors said. According to experts, the issue is disproportionately affecting pediatricians because they administer the majority of immunizations and are the lowest-paid specialists. Officials of the American College of Obstetricians and Gynecologists said they also are hearing about inadequate reimbursement from members who are reluctant to purchase Gardasil.

Some doctors issue prescriptions that are filled at a pharmacy instead of supplying the vaccines themselves. However, some insurance companies, such as CareFirst Blue Cross Blue Shield and Aetna, only cover vaccines supplied by physicians, the Post reports. Other physicians are reserving the vaccine for patients whose insurers have agreed to pay the physician a fee of about $140 minimum and others are requiring payment from patients upfront, according to the Post.

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Jon Almquist, chair of the American Academy of Pediatrics task force on immunization, in a statement released last week said that physicians "shouldn't be expected to subsidize the public health system and perform our jobs at a loss." He added, "We've carried this burden long enough." Gregory Moore, chair of ACOG's committee on gynecologic practice and director of student health at the University of Kentucky, said that some of the resistance to provide Gardasil is attributed to his specialty's lack of experience using vaccines, adding, "We need to make our members understand that (vaccines) are part of their practice."

According to the Post, insurance company officials said that the vaccine is expensive but that physicians are adequately compensated for providing it. Walt Cherniak, spokesperson for Aetna, said the company believes its reimbursement rate -- $120 plus a 5% markup and an administrative fee of $8 to $15 -- is "reasonable and sufficient," adding that Aetna encourages members to ask physicians for Gardasil. CareFirst spokesperson Jeff Valentine said that the company is "in the process of examining" its reimbursement rates, adding, however, that its rates are "competitive with what other insurers are paying."

Anne Francis, an associate clinical professor of pediatrics at the University of Rochester School of Medicine and Dentistry, said the economics of providing vaccines has changed dramatically in the past 20 years, adding that there is little room to recoup the costs for circumstances in which a vaccine would have to be discarded. "If I was a single practitioner, I would need to come up with $36,000 just to buy (the full three doses) of Gardasil for 100 patients," Francis said, adding, "That's a lot of cash to put out." Merck executives have said that the price of Gardasil is justified by its development costs and its value (Washington Post, 5/1).

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