How to maintain a successful flu vaccination program

The beginning of a new flu season marks a time for primary care physicians to consider how to vaccinate patients without falling into costly pitfalls.

“Some physicians are confused about vaccine schedules or about coding or they are afraid that they may lose money,” says Sandra Adamson Fryhofer, MD, an Atlanta, Georgia-based internist in solo practice and an adjunct associate professor of medicine at Emory University School of Medicine.

All of these obstacles are surmountable, says Fryhofer, who is also the American College of Physicians’ liaison to the CDC’s Advisory Committee on Immunization Practices (ACIP).  

“If coding and ordering are done properly, you should not lose money on vaccinations, and you should even be able make a small profit,” she says.

Be a champion

Before physicians dive into flu season, they need someone to lead a flu shot campaign for patients.

“When you are offering immunizations in your office, you need to find a champion, someone who will lead the march to encourage adult immunization and get patients on board,” says Fryhofer. A “champion” does not have to be the physician, but can be a nurse, office manager or medical assistant. And there can be many vaccine champions who take up the cause. 

“To champion it, you have to have resources,” she adds, noting that the ACIP website has extremely useful patient information sheets. Fryhofer keeps a copy of all the educational sheets in a notebook in each exam room, and asks the patient to read about the vaccine while she engages in other tasks. “These materials tend to answer about 95% of the questions that patients will ask,” she says.

Studies, including a recent one published in May in Vaccine by CDC staff, have shown a recommendation from a physician is one of the most important deciding factors in the patient’s decision to be vaccinated. Peng-Jun Lu, MD, Ph.D., one of the study leaders, told Medical Economics that incorporating vaccine discussion as part of the standard patient assessment can help reduce missed opportunities for adult immunization. 

“All healthcare professionals should routinely assess patient vaccine needs and recommend the appropriate vaccines to ensure their patients are protected against serious, sometimes deadly, diseases,” she says.

Fryhofer’s passion to ensure that patients receive appropriate vaccinations led her to develop “Move the Needle: Raise Adult Immunization Rates,” an online toolkit of resources, including information about vaccine schedules, the financial aspects of offering vaccines, coding information, updates and research and other vaccine-related materials that are relevant to medical practices.

A balancing act

Once practices have appointed a champion and compiled the necessary resources, it’s time to decide how to balance supply, cost and demand-a challenging process, according to Jack Chou, MD, a primary care physician in Baldwin Park, California.

“I always liken it to standing on the deck of a ship at sea and trying to play darts. It can even be hard to get your footing, let alone accurately hit the target on the dartboard,” he says.

Chou recalls that in 2015, when there was a vaccine shortage, his practice saw a delay in receiving its supply resulting in a smaller number of patients being vaccinated within the practice until late October or early November. 

Since they had used the small amount they received at the beginning of the season to vaccinate higher-risk patients, many of the practice’s other patients had already been vaccinated elsewhere, leading to leftover vaccines and a financial loss, Chou reports. 

One way that he addressed this issue was by continuing to offer vaccines through the end of flu season. And even though the vaccines had been administered at the end of March, which marks the end of flu season, it did not deter him from administering vaccines to the same patients at the beginning of flu season the following September.

To avoid ordering too many vaccines and being stuck with leftovers, Chou says, “I look at my patient volume, which is pretty consistent, and at their demand and patterns. I look at how many people we vaccinated last year, and if the practice is growing, I give a little buffer.” However, Chou recommends that smaller practices order in smaller quantities (with the exact number depending on patient panel) to reduce the risk. 

Persuading patients to get vaccinated can pose a challenge that has financial implications, according to Chou. In 2014-2015, the vaccine’s effectiveness rate was 19%, resulting in low patient confidence the next year, he reports.  

This was not the fault of the manufacturers, he says, but lies in the nature of the disease itself. “The medical community must make a judgment call regarding the substrains that will be addressed,” he explains. Manufacturers then produce them. But events occur that might change the predictions-for example, there can be a shift in antigens so that the type of flu changes during the season. 

Patients’ refusal to receive the vaccine, despite educational efforts, resulted in some financial loss, Chou says. But that started to change during the subsequent two years, when there was approximately a 50% success rate. By last year, things were better, so his practice vaccinated about 85% of the patients.

Vaccine purchasing groups

Ryan Kauffmann, MD, a solo primary care physician in Bellefontaine, Ohio, notes that at his previous practice he encountered significant financial difficulties in connection with the flu vaccine.

“We used to stock vaccines and sometimes put incredible amounts of money into them,” he recounts. “It was a model that made no sense financially. We had to get our orders in months ahead of time, and we had to pay even if the stock was not used up. And if we ran out, we could not replenish.”

Kauffman recommends vaccine purchasing groups as a cost-effective way of providing immunizations for patients. 

Vaccine groups purchase the physician’s current inventory and provide vaccines directly from the manufacturers at no cost, as well as offering automatic billing services and ways to keep track of inventory. 

However, vaccine purchasing groups can be tricky, warns Fryhofer. For example, many vaccine purchasing groups are willing to take back certain amounts of unused flu vaccines, but they do not always publish when or under what circumstances they will take them back. 

“Always ask,” she emphasizes. And physicians should check with their state, since vaccine purchasing groups can operate differently.

And however physicians get the vaccine-whether purchased directly from the manufacturer or through a vaccine purchasing group-it is important to keep track of inventory. The group can certainly help with this, but sometimes, simple is better.

Fryhofer says she uses a board attached to the side of the refrigerator on which she records when the vaccines are ordered, when they come in and how many are used. 

She advises physicians to look at the needs of their practice and determine what will work for them.

Know your codes

Insurance reimbursement for flu vaccinations has always been complicated but complications have mushroomed in recent years.

Coverage-related questions abound among physicians-for example, differences between Medicare Part B and Part D, Fryhofer says, noting that Part B covers the flu vaccine, while part D covers the shingles vaccine.

At present, under the Affordable Care Act, all ACIP-recommended vaccines have first-dollar coverage with no cost sharing, which can relieve the financial barrier for patients. Nevertheless, it’s important to be vigilant about reimbursement. Fryhofer notes that in order to be compensated correctly, proper coding is mandatory.

ICD-10 vaccine coding is simple, Fryhofer notes, as the diagnosis code is z23 for all vaccines. Things get a little more complicated with CPT codes (see sidebar on page 19).

Coding information is also available on the websites for the Centers for Medicare & Medicaid Services (CMS) and AAPC. 

Implement standing orders

One of the best ways of smoothing the process of vaccination is to have standing orders, according to Chou.

“We have patients fill out a questionnaire to be sure that there are no contraindications, and I leave standing orders so that the patient can get vaccinated, even before seeing me. Any practice can institute that type of protocol,” he says.

Fryhofer agrees that standing orders reduce barriers to adult vaccinations, adding that the Immunization for Action Coalition (IAC) offers information and support to practitioners seeking to implement standing order.

This includes protocols for establishing standing orders and who is authorized to administer the vaccines, steps for implementing standing orders and sample forms. 

“You are not going to get rich by administering vaccinations, but you also do not have to lose money,” Fryhofer says. She adds that, “vaccination has a much bigger purpose than just the dollar amount. You will be making your patient population healthier and protecting them from getting sick, which benefits not only the patient but also society and the population as a whole.”