As a family physician, I have been providing my patients with preventive care, including vaccinations, for nearly 40 years. I know that vaccines are safe, effective, and save lives. They are the best public health tool to fight disease and prevent illness, hospitalization, and even death. This is particularly true for my older patients, who are more at risk for infectious diseases and serious complications that can be prevented by vaccines.
The COVID-19 pandemic taught us that removing as many barriers to vaccination as possible is key to improving immunization rates and trust in the healthcare system. Unfortunately, the country is not where it needs to be with uptake. Part of the reason is that primary care physicians are unable to easily administer all recommended vaccines to their patients.
To break it down, Medicare Part B, which covers services provided at the physician’s office, covers four vaccines: COVID-19, flu, pneumonia, and hepatitis B for patients at risk. It also covers vaccines directly related to the treatment of an injury or direct exposure to a disease (e.g. rabies, tetanus). All other recommended vaccines are covered under Part D, Medicare’s separate prescription drug coverage.
When a patient receives a Part B vaccine from their physician, it’s free and their physician receives reimbursement for the vaccine product and an administration fee. Part D plans, however, contract with pharmacies, not physicians, so physicians typically must send Medicare patients to the pharmacy for vaccines such as shingles and RSV. Most doctors’ offices are not equipped to bill Medicare Part D.
This flawed system creates barriers to accessing recommended vaccines for Medicare beneficiaries who need them the most. These difficulties are compounded as new vaccines critical for seniors, including RSV, are covered only under Medicare Part D, which means most primary care physicians can’t offer the RSV vaccine in their offices. We still provide counseling on RSV and all other vaccines when our patients come into the office — but even when we agree together that they would benefit from the RSV vaccine, I must refer them to the pharmacy.
When the RSV vaccine became commercially available, I saw how this split coverage made it challenging to ensure that my patients were fully vaccinated against all fall respiratory diseases, with COVID-19 and influenza covered under Part B, and RSV under Part D.
Sending patients to another setting for specific vaccines results in fragmented care. Some of my patients struggle to make online vaccination appointments, rely on their family to drive them to their appointments, or have their own caregiving duties that make it hard to step away. I hope that my patients follow through with my vaccine recommendations, but I know that the hurdles they must jump over to receive vaccines in another setting make my recommended care inaccessible for many.
Complicating this problem, because pharmacies don’t always share vaccination records, I can’t tell whether my patients have received all recommended vaccines, and patients can’t always remember which vaccines they’ve received in other settings.
Patients seeking recommended vaccines such as RSV, tetanus (preventive), and shingles are often stuck between a rock and a hard place — forced to choose between getting vaccinated at their trusted doctor’s office and paying a high out-of-pocket fee or having to find an in-network pharmacy, make another appointment, and keep track of their own medical records.
Moreover, a patient’s individual health and medical history should be considered when selecting vaccines. Trusted primary care physicians are uniquely suited to consider how a patient’s medical history and other lifestyle factors may put them at risk for certain conditions. Enabling patients to have these conversations with their physicians and receive their vaccines in the same appointment will foster trust and improve vaccination rates.
As we continue to combat dangerous misinformation, the need to get Americans, especially vulnerable seniors, up to date on all recommended vaccinations has never been more imperative. One solution lies with our nation’s policymakers.
Congress has amended the Medicare Part B statute several times since the 1980s to provide access to preventive adult vaccines, including influenza, pneumococcal, and hepatitis B vaccines. The statute was updated again in 2020 to include the COVID-19 vaccine. Congress must update coverage again to allow Part B coverage of all Advisory Committee on Immunization Practices-recommended adult vaccines. This would allow beneficiaries to readily access vaccines wherever it’s most convenient — including from their usual, trusted source of care such as their family physician — and help improve vaccination rates.
The country has come a long way in disease prevention, in large part thanks to vaccines. To keep our seniors healthy, Congress should eliminate confusion and barriers to access, and allow physicians to vaccinate all eligible patients.
Steven P. Furr, MD, is a family physician in Jackson, Alabama, and president of the American Academy of Family Physicians.
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