DC Medical Malpractice & Patient Safety Blog

If you had chicken pox as a kid, you have a one-in-three chance of developing shingles in your old age, and that can spell months or even years of searing pain. There's an effective vaccine to protect against shingles, but it's seldom used, and therein lies a story of the inadvertent clash between patient safety and insurance reimbursement practices.

Shingles is a re-eruption of the old chicken pox virus (known as herpes zoster) that sits dormant in the body of anyone who had childhood chicken pox. Shingles hits about one million Americans each year, and it's very hard to treat. It can go anywhere in the body, and victims often say the pain is worse than bearing a child -- and it lingers much longer too.

A new vaccine, approved by the FDA in 2006, can cut the risk of shingles by more than half, with just a single shot in the arm. The vaccine is now recommended by the Centers for Disease Control for anyone over age 60.

But only around one in twenty people are getting the shingles vaccine, according to a survey of primary care doctors by researchers at the University of Colorado, published in the Annals of Internal Medicine, and discussed by Dr. Pauline Chen in a column in the New York Times.

The culprit is money. The vaccine costs $160 to $195 per dose, and both private insurers and Medicare require patients to pay up front and get reimbursed later. Many doctors' offices, which lose money when even one in ten patients doesn't pay their vaccination fee, have stopped stocking the vaccine, and it's not much easier to get by taking a prescription to a pharmacy, according to the article.

Dr. Laura Hurley, the lead author of the new study, told the Times:

“Shingles vaccination has become a disparity issue. It’s great that this vaccine was developed and could potentially prevent a very severe disease. But we have to have a reimbursement process that coincides with these interventions. Just making these vaccines doesn’t mean that they will have a public health impact.”

Elderly people are particularly vulnerable to shingles because they often have a less robust immune system to fight off the virus. And if you've known anyone who has had an episode of it, the cost of the vaccine seems cheap compared to the suffering that could be avoided.

Here's an informative web page from the CDC with answers to common questions about the shingles vaccine.

The Advisory Committee on Immunization Practices, a panel that advises the federal government, is recommending that adult smokers under 65 should get a pneumococcal vaccine that was previously only recommended for anyone 65 or older. Federal officials usually take the advice of this panel, according to the article, and this is the first time an influential body of scientists has recommended a vaccine specifically for smokers. From the article:

Studies have shown that smokers are about four times more likely than nonsmokers to suffer pneumococcal disease. Also, the more cigarettes someone smokes each day, the higher the odds they'll develop the illnesses.

Why smokers are more susceptible is not known for sure, but some scientists believe it has to do with smoking-caused damage that allows the bacteria to more easily attach to the lungs and windpipe, said Dr. Pekka Nuorti, a medical epidemiologist with the Centers for Disease Control and Prevention.

However, some scientists doubt the usefulness of this vaccine for smokers under age 40.

The vaccine protects against a variety of pneumococcal bacteria that can cause pneumonia and other serious lung infections.

Laura Landro, in her column "The Informed Patient," discusses the problem of adults neglecting to get vaccinated for new illnesses. Not only that, but adults forget or are unaware that some childhood vaccinations lose efficacy after some time and need to be re-done. Skipping pre-travel vaccinations is also a common error.

Part of the problem is insurance: not only is vaccination for the very young more likely to be encouraged, but it is also more likely to be covered by insurance providers.

The whole column is worth a read, but here are some disturbing statistics Landro cites:

-only 2.1% of adults are vaccinated for tetanus, diphtheria and whooping cough, despite the existence of a combination vaccine for all three.

-only 1.9% of adults have been vaccinated for shingles. The shingles vaccine is recommended for all adults over 60.

-only 10% of women from 18 to 26 have received the vaccine for human papillomavirus, which can lead to cervical cancer, and which most insurance providers will cover.