Primary Care/Managed Care

Making vaccines free to providers may not improve childhood immunization rates

Since 1983, provider costs for purchasing one full series of vaccine for a child (all doses of standard vaccines up to age 2 years) have increased 10-fold. Some believe that Federal initiatives that would lessen provider vaccine costs would increase the number of children with up-to-date immunizations. However, a new study, supported in part by the Agency for Health Care Policy and Research (HS07286), suggests that this may not be the case.

Led by Gary L. Freed, M.D., University of North Carolina researchers calculated patient charges for diphtheria-tetanus-pertussis (DTP), measles-mumps-rubella (MMR), Haemophilus influenzae type b (Hib), and combined (DTP-Hib) vaccines, as well as the charges for well-child visits in three States with varying vaccine financing systems. Results showed that in Massachusetts, which supplies providers with free vaccines and limits physicians to a "reasonable administration fee," average patient vaccine charges were 10 percent lower, but well-child visits averaged $10 to $13 more than such visits in North Carolina and Texas. Neither regional variation in cost of living nor Medicaid reimbursement rates explained this difference.

It was not clear whether Massachusetts physicians shifted vaccine costs to other preventive services to compensate for lower allowable immunization charges. If such cost shifting occurs, current Federal immunization initiatives to lower or eliminate provider vaccine costs may not provide increased access to preventive health services. In effect, lowering charges for immunizations may not lower a family's overall outlay for health care because well-child visits do not always include immunizations, conclude the researchers.

For more information, see "Variation in patient charges for vaccines and well-child care," by Dr. Freed, Sarah J. Clark, M.P.H., Thomas R. Konrad, Ph.D., and Donald E. Pathman, M.D., M.P.H., in the April 1996 Archives of Pediatric and Adolescent Medicine 150, pp. 421-426.

Conference focuses on the changing interface of primary and specialty care

About 4.5 percent of patient contacts with primary care providers result in referral to a specialist. Rates of referral vary widely however, and there is great uncertainty about appropriate referral practices. Managed care organizations (MCOs) often use the primary care physician as a gatekeeper to reduce unnecessary referrals and save costs.

It has been argued but not proven that health outcomes and patient satisfaction can be jeopardized in the process of referral and that for some complex conditions, such as diabetes, care for that condition provided by a specialist might be more appropriate. To tackle some of these issues, the Agency for Health Care Policy and Research convened a conference in September 1995 entitled, "Research at the Interface of Primary and Specialty Care."

The purpose of the conference was two-fold: to assess the current state of research related to integration of primary and specialty health care services, including practices of referral and consultation; and to elicit suggested topics for future research in this area. Speakers at the AHCPR conference noted that until such information is available, efforts to develop referral guidelines will be premature. There is an urgent need for information that can lead to more science-based decisions about when and how to refer patients, point out AHCPR staff members David C. Lanier, M.D., and Carolyn M. Clancy, M.D. Dr. Clancy is Director of AHCPR's Center for Primary Care Research.

For an overview of the conference, see "The changing interface of primary and specialty care," by Drs. Lanier and Clancy, in the March 1996 issue of The Journal of Family Practice 42(3), pp. 303-305.

The full text of the Conference Summary Report (AHCPR Pub. No. 96-0034) is available from the AHCPR Publications Clearinghouse; call toll free 800-358-9295. Online highlights of the Conference Summary Report are also available.

"Medical necessity" is an imprecise term

The term "medical necessity" has been used by health insurance plans for 30 years to define the limits of their benefits coverage, despite widespread disagreement about its meaning. Over the years, the term has evolved from an insurance concept controlled for the most part by practicing physicians to a rationale used by health plan administrators and medical directors to control the use of scarce resources, according to Linda A. Bergthold, Ph.D., of the Lewin Group. In a presentation at a 1995 symposium on medical necessity, cosponsored by the Agency for Health Care Policy and Research, she discussed the historical and current use of the term and its impact on national health care debates.

Dr. Bergthold suggests that several factors have contributed to the redefining of medical necessity. These include the growth of managed care, shifts in the health care delivery system away from the traditional insurance model for which the term "medical necessity" was devised, a lack of consensus within the medical community on treatment options, and a paucity of clinical evidence about the merits of one treatment over another for the same condition.

In a recent paper summarizing her presentation, Dr. Bergthold calls for a new definition of medical necessity—one that would remove the vagueness inherent in the term—and processes for applying it that are clearer and more collaborative. A redefinition becomes particularly important, notes Dr. Bergthold, as the population ages, new technology continues to press its findings upon the medical consumer, and the ability to pay for wonder drugs and treatments becomes further constrained.

Details are in "Medical necessity: Do we need it?" by Dr. Bergthold, in the Winter 1995 issue of Health Affairs 14(4), pp. 180-189.

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