RENEE MONTAGNE, host:

When it comes to immunizing children, a growing number of pediatricians and family doctors say they are not being paid enough. A study in this month's journal Pediatrics found a wide variation in how much doctors earn for childhood immunizations. NPR's Brenda Wilson reports.

BRENDA WILSON: When New Jersey pediatrician Doctor Richard Lander started out 26 years ago, giving children shots was pretty simple.

Dr. RICHARD LANDER (Pediatrician, Livingston, New Jersey): There were probably half a dozen vaccines that we gave. The vaccine manufacturer charged me x dollars, I charged my patients y dollars, they paid, and they submitted it to their own insurance companies.

WILSON: These days, children will get more than 20 vaccines by the time they are 18, at a cost of about $1,500. It can seem simple, a routine visit to the pediatrician for 20-month-old twins, Dominic(ph) and Angelina(ph), who have come for polio and influenza shots. But first, a wriggling Dominic has to submit to a well-child visit with one of Doctor Lander's partners, Doctor Amy Metar(ph).

Dr. AMY METAR (Pediatrician, Livingston, New Jersey): Hi there, Dominic. Can we take a listen to you?

(Soundbite of crying)

Dr. METAR: I know, buddy. I'm sorry.

WILSON: There's a fee for the well-child visit, the vaccine, and a fee for administrating the vaccine.

Dr. LANDER: We will bill for the vaccine we've administered, and we will bill for the vaccine administration fee. Many managed-care organizations will say, why are you so interested in getting paid more for the vaccine administration fee? Look how well I pay you for the vaccine. We're talking about a product and we're talking about a service. Don't pay me for one and not pay me for the other.

WILSON: But not all pediatricians and family practitioners pay such close attention to the practice as a business. Doctor Gary Freed, of the University of Michigan Health Systems, recently conducted a study in pediatrics. He surveyed pediatricians and family practitioners in 76 private practices across the country.

Dr. GARY FREED (University of Michigan Health Systems): We found some physicians who, quite honestly, didn't know what they were paying for vaccines and had to dig up records to figure that out.

WILSON: Many physicians were, in fact, losing money on childhood immunizations.

Dr. FREED: It turns out that some physicians were paying over three times what other physicians were, for the exact same vaccine. By the same token, we found that some physicians were being reimbursed more than twice as much as other physicians for the exact same vaccine.

WILSON: There are a host of expenses associated with childhood immunizations - administrative costs for the time it takes to order and stock the vaccines, the cost of refrigerators to store vaccines, electricity, and insurance.

Dr. FREED: Some of these vaccines cost over $100 a dose. And if you're thinking about stocking, you know, 60 to 100 doses in your practice, that's a significant capital outlay while you're waiting to get reimbursed, from anywhere from 30 to 90 days.

WILSON: In another survey of more than 1,000 pediatricians and family practitioners in the same issue, at least a fifth of family practitioners say they can no longer afford to vaccinate children, which can be a problem particularly in rural areas of the country where there are often no alternatives. Only a few pediatricians say they are considering not vaccinating, but 40 percent of them feel inadequately paid by insurers. That includes the government, the largest purchaser of vaccines, which provides them for free for children who are not insured. But the government pays only a nominal fee for administering the vaccines.

Susan Pisano, a spokesperson for America's Health Insurance Plans, an advocacy group for health insurers, says private insurers are being asked to pick up the government's slack.

Ms. SUSAN PISANO (Spokesperson, America's Health Insurance Plans): What has happened is that because government, Medicare and Medicaid, typically pays providers, doctors, and hospitals less, those doctors and hospitals have been expecting greater payment from employer-sponsored plans. That cost shift probably amounts to about 10 percent of my premium and your premium.

WILSON: Most doctors and pediatricians, she says, are operating at a profit, and employers and consumers should not have to pay for the inefficient ones. To reduce his costs, Richard Lander, who's chairman of the American Academy of Pediatrics Committee on practice management, started a group purchasing organization for doctors to buy vaccines at a discount. But he says he's still losing money on insurers; one insurer wanted to pay him even less than the federal government does.

Dr. LANDER: They were unwilling to give a better payment, and I decided to drop the company. I couldn't bear anymore to be paid so poorly.

WILSON: And if more pediatricians and primary care physicians stood up to insurers, Landers says, they wouldn't be the poorest paid in the medical profession. Currently, insurers and pediatricians and family practitioners are discussing how to remedy the situation. Brenda Wilson, NPR News.

MONTAGNE: It's Morning Edition from NPR News.

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