It's not rocket science to provide basic health care. But an arcane billing system is keeping a simple program for free flu shots from taking off in Rhode Island.
Okay, folks, it’s flu shot time again.
You may recall that little Scituate, Rhode Island, a pretty rural exurban town of 10,000 in the green hills west of Providence, is still the only non-Indian-reservation place in the U.S. where everyone has guaranteed access to primary health and dental care. We manage to do that through the efforts of a group of volunteers called the Scituate Health Alliance.
The Alliance has managed to raise enough money for basic health and dental care by putting together some contributions from town government, some Community Block Grant Funds, some donations from local folks and the money raised from bake sales and apple sales, and some grant money – buying primary medical and dental care for $25 per person per month from local medical and dental practices. Not complicated, very effective, and pretty simple and cool, particularly when we look back on the mess and chaos of what passed for health care reform over the last year and a half.
That self-same Scituate Health Alliance, the same rowdy bunch of volunteer of nurses, EMTs, dentists, doctors, carpenters, pharmacists, business owners, orchardists, and administrative assistants, has also been doling out flu shots to everyone in Scituate who wants one each fall for the past nine or ten years. Every year, we get together and set up shop at the high school, the local libraries and a couple of fire stations, and pump vaccine into the arms of anyone who will show up and roll up a sleeve. It’s pretty simple and effective – we can do a couple of hundred shots an hour if we need to, and we have the logistics down pat, so we know how to manage the numbers when the crowd balloons.
In a typical year give out five or six hundred shots, though we could do 10,000, which is the population of Scituate, if we could only get everyone to show up. No lights and sirens, probably doesn’t change the course of the Nile, because the flu shot itself, while a decent thing overall, isn’t magic, but at least everyone in town gets an equal, er, shot, at basic health care.
So here’s where it gets interesting. Also about ten years ago, this writer entered into a communistic conspiracy with a legislator who is now Rhode Island’s Lieutenant Governor, to write a little legislation that would have the state buy flu shots for all Rhode Islanders. The legislation was pretty simple, and was designed to address some marketplace chaos which also happened each fall, the complicated set of cat, rat and mouse games played among medical practices, flu vaccine manufacturers, vaccine distributors, and health insurance companies. All those games, having mainly to do with flu vaccine price, supply and profitability (and everyone’s wanting a cut of the take), always resulted in vaccine shortages in October, when it’s time to give the vaccine, and a glut of vaccine in January, when the first flu has already blown through. The process got so predictably crazy that most doctors’ practices decided to quit giving the vaccine, because buying and getting paid for the stuff was too damned complicated.
In other words, we had a medical way of improving people’s health, but it wasn’t getting to the people it might benefit because of how the market worked — or didn’t work — to provide health care.
But in Rhode Island, we already had a system to buy and distribute vaccine to kids. Using that system, the state bought vaccine for all our children using money from the Centers for Disease Control (CDC) and from all the health insurance plans. The state distributed vaccine for free to all the medical practices that vaccinated kids, charged health insurance plans for their share, based on how many kids the plans had enrolled. And — surprise, surprise — Rhode Island consistently had the best childhood immunization rates in the U.S. For childhood flu vaccine, it was almost as if Rhode Island had a (don’t tell anyone) health care system. It was inexpensive. It was efficient, it treated all Rhode Islanders equally, and it worked.
So when we started to think about straightening out the mess in adult flu vaccine, we didn’t have to look very far to figure out how to fix it. We’d just do for adults what we did for children. State buys all the vaccine, gives it for free to doctors’ offices. Doctors’ offices immunize all their patients. Health insurance companies ante up for the cost of the vaccine, based on how many people in the state they insure. Pretty simple. We had a local model with a great track record, and a real, albeit small, problem that we could solve.
We also had an existing state agency that was already involved in this work and a great public outcome one might expect as a result. (We projected saving about 3000 lives a year, if we could get everyone immunized – probably overstated, but it would be hard not to save a couple of hundred lives a year out of a population of one million, and saving a couple of hundred lives is still something most people think is worth doing.)
So we wrote the legislation, dealt with the opposition (from vaccine manufacturers, who didn’t want to have to deal with the market power of the state as a single purchaser, and, what do you know, from the state health department, which didn’t want the extra work), and got the legislation passed. Pretty cool beans. Rhode Island’s adult flu vaccine immunization rate becomes the best in the U.S.
Sorry guys, public health is not rocket science. All you need is a little health care system, plus the ability to add and subtract, multiply and divide.
Flash forward ten years. The Scituate Health Alliance starts immunizing an entire community. Vaccine supply ought to be cake, right? Wrong. This is health care system, where money comes first, control comes second, and people’s health is an afterthought.
Here’s how that wonderful influenza vaccine legislation, written in part by yours truly, got implemented. Anybody who wants to vaccinate people needs to bill each person’s insurance company singly, for each and every vaccine, even though we are doing the same thing over and over again, a process that takes exactly 15 seconds per person. (Trust me, not only am I a doctor, but I’ve timed myself. I can vaccinate 4 people a minute, or 240 an hour. The only limitations are crowd control and parking.)
The blinking vaccine costs the CDC about $9.00 a dose, and you and me about $12.00 each (which includes 75 cents of federal excise tax, meaning the federal government itself is taking ten percent off the top of an effective public health process!!!). I’m guessing that one dose of flu vaccine actually costs less than $5.00 per person to make, once you strip off vaccine manufacturer profit and marketing costs. Influenza vaccine cost $0.47 a dose in 1992 when I started practice, which was just before we let the dogs of health care profiteering loose in the US.
The insurance company, in theory, counts up all the bills they get, and then multiplies the number of shots given to people they insure by the costs of the vaccine, and writes the state a check. And then they pay each vaccinator some amount of money, which ranges from one penny (I kid you not) to $50, for giving the vaccine and sending the bill.
That’s how it works. Well…maybe sort of. Turns out that there are all sorts of issues around wild stuff like self-insured employers, secondary insurances, provider contracts and a hundred other things, so while it’s simple enough for the insurer to write the state a check for a certain number of people who got flu shots, that process generates an avalanche of electronic transactions, in which bills, and parts of bills, and co-pays, and coinsurance and secondary insurance and fee schedules and receipts percentages are all charged and tallied, accounted for and distributed, all for a little shot that takes fifteen seconds to give and costs five bucks. So the whole system now turns on the vaccinator sending a bill.
But the Scituate Health Alliance doesn’t send bills. We are about bringing needed health care to a community, not about sending bills.
So guess what? No one can figure out how the state can possibly supply us with vaccine, because we don’t want to build a whole billing department for a 15-second shot, and we don’t want to bill our friends and neighbors for a shot that no one really wants to get but that ends up protecting each person, and the community as a whole.
We have three options:
1) We can beg the state health department to make an exception and just give us the blinking vaccine (which they did last year), in which case the health insurance companies make out like bandits; that’s because most people who live in Scituate actually have health insurance and because the insurance companies don’t have to pay us the administrative fee that they pay to every other vaccinator — and they probably don’t have to pay the state for the vaccine either.
2) We can arrange a deal with a private company, to do the billing for us, and fork over half of what we get from the administrative fee; this set up would probably give us the best shot at getting the vaccine from the state.
3) Or we can just go buy the vaccine privately, in the only state in the U.S. that has a state program to buy vaccine for everyone.
Last year the state health department gave us the vaccine, mumbling something like, “Don’t tell anyone we did this,” as if what they did—helping get a whole town immunized by a bunch of volunteers who actually want to protect the health of our friends and neighbors – were evidence of moral turpitude. This year the state health department said it couldn’t possibly just give us vaccine again, and suggested that we beg every health insurance company individually for enough vaccine for the people in our community that each company insures. This year, if the health insurance companies say no, as they probably will because it’s better for their bottom line to do so, we’ll probably just buy vaccine ourselves, paying top dollar; the vaccine manufacturers and the vaccine distributor will do ok, and we’ll get to vaccinate everyone who wants a shot, and the health insurance companies will make out like bandits, because they’ll get paid for people to have vaccine as part of people’s premiums but they won’t have to pay out a dime for the vaccine itself.
I am sorry to report that Health Care Reform 2010 a.k.a. the Patient Protection and Affordable Care Act of 2010 probably isn’t either reform or protection, and won’t do anything to change this mess. Health insurance companies will keep getting richer. And the rest of us…?
Add, subtact, multiply, divide…Is there any intelligent life left in the United States?