Today we bring you the story of a patient seeking the RSV vaccine 鈥 and how her frustrating journey illustrates why it can be so hard in the United States to get an important medicine recommended by federal regulators.
Hannah Fegley of Silver Spring, Md., says she spent seven hours on the phone last month 鈥 the eighth month of her pregnancy 鈥 with insurers, pharmacy benefit managers and half a dozen pharmacies trying to obtain Pfizer鈥檚 new RSV shot, called Abrysvo.
Respiratory syncytial virus puts of babies in the hospital each year because their tiny airways don鈥檛 tolerate the inflammation. While most recover with supportive care, as many as 300 kids under 5 years old die each year and the majority of them are under 1. A bad case of RSV in infancy can mean a lifetime of asthma. 聽
Fegley says two of her friends saw their babies land in intensive care last year, . So she was eager to get the shot; she has a 4-year-old in preschool who, she says, 鈥渂rings home every virus.鈥
One of KFF 国产精品视频 News鈥 signature projects is the Bill of the Month, where readers and listeners send us stories about how the U.S. health system is failing them. Often, the problems they encounter connect directly to holes in government policy. Fegley鈥檚 story shows how regulators鈥 recommendations trickle down into a fragmented health system 鈥 leaving patients in the lurch.
The Pfizer vaccine (list price: about $300), confers immunity to the fetus through the mother. As an alternative, the Advisory Committee on Immunization Practices also recommended AstraZeneca鈥檚 Beyfortus (about $500), a monoclonal antibody against the virus to administer to babies after birth. Fegley鈥檚 obstetrician didn鈥檛 carry the vaccine. So she gave Fegley a prescription to get it at a pharmacy, predicting (correctly) that many pediatricians wouldn鈥檛 stock Beyfortus.
Pharmacies typically stock RSV vaccines because the CDC also recommends them for people over 60 鈥 a large and lucrative market, even though scientists and public health authorities agree the more. There are two different RSV vaccines approved for older Americans: the Pfizer shot, which is also approved for pregnant women, and a GlaxoSmithKline shot that is not.
Fegley鈥檚 insurer uses CVS-Caremark as its pharmacy benefits manager, which of course uses CVS Pharmacy. (Both of CVS 国产精品视频 Corp.) And CVS, she discovered, only stocks the GSK vaccine.
(Is your head spinning yet? Hers was. And she is health-care literate 鈥 a social worker whose husband is a doctor. 鈥淲e鈥檙e told we have choice, but we really do not,鈥 she said.)
After a phone complaint, a Caremark representative granted Fegley an 鈥渙verride鈥 allowing her to try other pharmacies. She called them, but many said they鈥檇 only give the Pfizer shot to people 60 and over.
鈥淲e鈥檙e currently completing the final steps needed to offer the maternal RSV vaccine and hope to make it available at our pharmacies soon,鈥 said Matt Blanchette, a CVS 国产精品视频 spokesman representing Caremark and the pharmacy. 鈥淧atients should check with their insurer to confirm if the vaccine is covered by their individual plan.鈥
One smaller pharmacy said by phone it had a dose for Fegley, but when they checked her insurance at the counter, it was denied. She filled out forms to get a shot at both Costco and Walgreens. Denied.
She didn鈥檛 want to pay $300 or more for the shot out-of-pocket because she knew that under Obamacare, most insurers must cover all ACIP-recommended vaccines free of charge. So how can it be so hard to obtain a shot that the FDA and CDC say can save babies鈥 lives? Let us count the ways.
- One: The Affordable Care Act gives insurers more than a year after a new vaccine wins ACIP鈥檚 stamp of approval to start covering it.
- Two: To keep costs down, pharmacies try to get deals on similar products by contracting with just one drugmaker. GSK its application to the FDA for approval to give its shot to pregnant women.
- Three: Many pharmacies don鈥檛 like giving pregnant women shots, fearing liability.
- Four: Both obstetricians (for the Pfizer shot) and pediatricians (the monoclonal antibody) have a hard time stocking such expensive medicines 鈥 particularly with insurance reimbursement uncertain.
鈥淐ost is the big issue,鈥 said Steven Abelowitz of Coastal Kids, a big California group practice. 鈥淔or us, it was a tough, risky decision: We鈥檝e spent millions to order batches and we don鈥檛 know if we鈥檒l get reimbursed,鈥 he said. 鈥淪maller practices just don鈥檛 have the money.鈥
There鈥檚 a happy-ish ending: This month, a Caremark representative left Fegley a voice mail saying she had an override to get the Pfizer vaccine at Costco for $105 out of pocket. If she wanted it free, the rep added, she should contact her husband鈥檚 employer.
With some resentment, she says, she paid for the shot.
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