Flu Shots at Wal-Mart But Not in Physicians' Offices

The San Diego Union-Tribune reported on the troubling state of influenza vaccination this season. Physicians in California are having great difficulty getting the stocks of vaccine that they ordered. "Three in four doctors responding to a California Medical Association survey had not received their full vaccine supplies as of Nov. 3. More than half of them had not obtained any vaccine, and 70 percent had to reject high-risk patients' requests for flu shots. The article quoted the CEO of the Medical Association, Dr. Jack Lewin:

Despite being assured each year that supplies will be adequate and delivered to physicians on time, here we are again. We have high-risk, sick and elderly patients left unvaccinated. This is intolerable."

What went wrong? According to the Union-Tribune article, vaccine manufacturers preferentially shipped supplies of vaccine to high-volume customers, like big-box stores such as Costco, Wal-Mart, and Albertsons on the west coast of the US. Quoting Dr. Wayne True, a physician in La Mesa, "This year's vaccines are going to where the money is - to the 'big box' customers first." Physicians often "go through pharmaceutical distributors for their vaccine supplies, while some big retailers are able to place bulk orders directly from vaccine manufacturers."

Neither the vaccine manufacturers, distributors, nor "big-box" stores seem to want to take responsibility for this situation.

• Alison Marquiss, a spokeswoman for Chiron, one of the three remaining US vaccine suppliers, admitted that "its priority shipments were earmarked for high-volume customers, as standard practice for all manufacturers of vaccine, according to the Union-Tribune. Marquiss said, "there are different contractual terms for different orders. It would be a bit naive not to realize that."
• David Aguilar, of Physicians Sales and Service, a distributor of vaccines, accused, "Physicians are panicking." Furthermore, "there are a lot of sales reps here that don't want to deal with the flu (shots) because of what's been happening.... It's a headache for everyone."
• Michael Mastormonica, coordinator of Costco' influenza program, said it should be up to the government, and that the Center for Disease Control (CDC) should "step in and stipulate distribution, saying these providers take priority over others." But a spokesman for the CDC noted that the agency "has no regulatory authority whatsoever to mandate anything when it comes to supply and demand of influenza vaccine."

As a physician, it seems to me that the true measure of a health care system is how it takes care of the sickest and neediest patients. Here we have a system that can supply influenza vaccine to relatively healthy people who show up at big-box stores, but not to sick, high-risk patients in doctors' offices.
The system for distributing influenza vaccine has been taken over by large organizations, vaccine manufacturers, distributors, and large retailers, none of whom apparently put the needs of sick patients first, and seem very good at avoiding any responsibility for doing so. Note that the distributors' sales reps were complaining they were getting a headache from the situation, but an elderly, high-risk patient may get far more than a headache should they acquire influenza. To reiterate what Dr. Lewin said, "This is intolerable. We need a fair, equitable, and efficient delivery system."
And just to add insult to injury, some of the more credible proposals to make physicians subject to "pay-for-performance" would measure such performance by, among other criteria, the proportion of a physicians' high-risk patients who get influenza vaccine (see, for example, the recommended "starter set" of measures here.) Were California physicians to be subject to these measures this year, and perhaps some of them are, physicians whose suppliers failed to send them enough influenza vaccine would be rated as performing poorly. No wonder many of us physicians are skeptical that such measures will fail to deal with the real shortcomings of the health system's performance, and will perversely penalize some physicians who may be trying the hardest to take care of the sickest patients.