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Shingles Vaccine Proves Painful
By Sandra G. Boodman, The Washington Post
September 25, 2007
Clara Davidson is refusing to get vaccinated
against a recurrence of shingles.
Clara Davidson is the kind of person public health officials had in mind when they approved the shingles vaccine last year.
At 83, she recently suffered through a painful bout of shingles, a reactivation of the dormant virus that causes chickenpox. It was, she recalls, "quite nasty," an experience she is eager to avoid repeating. With the possibility of a recurrence in mind, her suburban Maryland internist urged her to get the shot known as Zostavax, which an advisory committee to the federal Centers for Disease Control and Prevention has recommended for Americans 60 and older.
But Davidson's willingness to be immunized evaporated once she discovered the unusual rules governing the vaccine: Medicare won't pay for it, as it does flu shots and other vaccines; her doctor doesn't stock it, so she'd need to pick it up at a pharmacy and bring it back to his office within 30 minutes; and her supplemental Medicare Part D prescription drug plan doesn't cover it.
As a result, the Columbia resident is just saying no to the shot that would cost her $200.
"I can afford to do it, but I got my back up and I'm not going to," said Davidson, who regards her refusal as something of a moral issue. "More people should take a stand; $200 is a horrendous amount of money. The drug companies are rolling in money and should help pay instead of running full-page ads," she said, citing prominent advertisements for the vaccine taken out by manufacturer Merck earlier this year.
Vaccines that are particularly beneficial for older Americans, including those for flu and pneumococcal pneumonia, have been fully covered under traditional Medicare rules. Zostavax is the first vaccine that is -- or isn't -- covered by Medicare Part D drug plans, a byzantine patchwork with a wide variety of rules and reimbursement rates.
"It's become a free-for-all, " said Kenneth Schmader, chief of geriatrics at Duke University Medical Center who heads the research committee for the American Geriatrics Society. While most Part D plans cover Zostavax, he said, some practices are charging as much as $500 per shot (doctors pay about $150 per dose) in an effort to recoup their overhead. Zostavax, which is a live virus, must be handled carefully and remain frozen until shortly before it is injected.
The result, he said, is that many patients who could benefit from the vaccine and avoid shingles and its severely painful aftermath known as postherpetic neuralgia -- nerve damage that can persist for months -- aren't being immunized. Health officials estimate that 35 million to 40 million Americans are candidates for the shot; according to Merck, 1 million doses of the vaccine have been sold.
Merck spokeswoman Mary Elizabeth Blake said that the company "is working to address logistical challenges" confronting patients. "Progress is being made."
"We certainly believe it is priced appropriately and reflects the value of this vaccine," she added.
Most health plans, Aetna included, require that patients pay doctors upfront for the full cost of the vaccine and its administration and then file for reimbursement.
"The amount of reimbursement would depend on the plan a person is in," Aetna spokesman Walt Cherniak said in an e-mail.
Some doctors say that while they are enthusiastic about the vaccine, they don't stock it, fearing they won't be adequately reimbursed. Similar concerns have affected the availability of Gardasil, another new Merck vaccine aimed at girls and young women that is designed to prevent cervical cancer.
Washington internist Alice Fuisz said her patients are keen to get Zostavax because many have a friend or relative who has endured shingles. She and her partners give such patients a prescription and send them across the street to a drugstore to pick up the vaccine, which they then administer.
"It's one of the few vaccines we aren't stocking," she said, largely because "figuring out the logistics of the payment system sounded overwhelming." Last year, Fuisz added, her practice bought too much flu vaccine and "lost a lot of money."
"We never know what insurance is going to cover," said Joan Irvine, practice administrator for Montgomery Internal Medicine Associates in Olney, which stocks Zostavax. More than 112 patients have been immunized so far, she said. "The patients end up paying for it, and that's the biggest problem," she noted, because some who need it can't afford it.
Duke's Schmader notes that the uncertainties have created an additional obstacle for patients: the 30-minute rule.
For a 75-year-old with health problems, being told to pick up the vaccine at a pharmacy and bring it back to a doctor's office in half an hour or less may be no easy task.
"You can see how daunting that might be," he said.
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