Pediatricians everywhere know that vaccines constitute a large and necessary part of their practice's annual budget. They also know the importance of storing those vaccines properly so as not to lose their inventory and financial investment. Navigating the choices surrounding vaccine buying and storage can be daunting, and many questions can come up in the process. To help shed light on the subject, we talked to our client, Dr. Graham Barden, III, MD, FAAP, from Coastal Children's Clinic in North Carolina to get his insights and expertise.
Dr. Barden's father started Coastal Children's Clinic in 1952 as a solo pediatrician in a small town. After seeing his father enjoy working as a pediatrician, Dr. Barden decided to pursue pediatrics as well. He completed undergraduate and medical school at Duke University, and his residency at Vanderbilt University.
After completing his residency, Dr. Barden joined his father's practice in 1985 as the 4th pediatrician on staff. Since that time, the practice has grown to include 8 full time pediatricians, 1 part-time pediatrician, and 3 other providers. Coastal Children's Clinic has 3 offices, about 20 miles apart.
We began by asking Dr. Barden about vaccine pre-buying. Here's what he had to share.
Question: What are the advantages of pre-buying vaccines? Why do it?
Answer: Frequently, vaccine manufacturers will give pediatricians a 'heads up' that vaccines will have an increase in cost on a certain date. And if the pediatrician orders vaccines on the day before and accepts all of it when it comes in, they will have the old price for as much as they order. But it all arrives in a single large shipment.
Payers often take a while to respond to cost increase with payment increases. So the pediatrician has the choice: do you front extra cash for a few months and buy the extra vaccines to guarantee you will not be in a situation where the cost is above the payment? Or do you just go on as always and hope the price increase is instantly matched with a payment increase?
According to Dr. Barden, even when you factor in things like the large up-front expense, and any interest you would have to pay on a bank loan or credit card, you will still typically come out ahead by pre-purchasing at the lower rate. As long as you have adequate storage, using a flexible line of credit where the balance is paid quickly during the loan is a good practice for pre-buying.
Question: Should a pediatrician belong to a vaccine buying group?
Answer: All pediatricians should belong to vaccine buying groups in order to maximize profit on private purchase vaccines. In a buying group, each member is independent and can order the specific amount that they need. You should always be able to purchase vaccines at or below the listed CDC 'private' price. The buying group will generally tell you about impending price increases. You then need to calculate how many private dosages of that vaccine you use, how many extra months you want, and that the expiration date generally covers that many months. You'll also need to verify that you have enough extra space in your vaccine refrigerator to safely store the extra vaccine. With private vaccine, if the refrigerator fails and the vaccine is declared wasted, you can always send the non-flu vials back to the manufacturer for new replacements at no cost after the expiration date. So you are not really at a larger financial risk.
Next, Dr. Barden spoke about proper vaccine storage. In order to safely store your vaccines, you need to have the right equipment. Here's what he had to say on the subject.
Question: What are the advantages of having a refrigerator made specifically for vaccines?
Answer: A pharmaceutical grade refrigerator has a more constant temperature throughout the interior. Vaccines can be safely stored on top and bottom shelves. There is a fan for constant air circulation, and so it is unlikely to put refrigerated vaccines at risk for freezing. Food service refrigerators are made for food - to be able to rapidly cool down warm food. But subjecting a head of lettuce to freezing air is not the same risk as freezing $100,000 worth of vaccine. Domestic combo (freezer and refrigerator in same unit) refrigerators should never be used, even if allowed by the CDC/VFC inspectors. The risk of freezing vaccines in a refrigerator cooled by freezer air is too dangerous.
Question: Aside from storage temperature, what else do you need to be aware of when managing your vaccine inventory?
Answer: Expiration dates need to be tracked, and stock rotated to use the oldest first. The refrigerators need to have enough extra space to make the storage of extra stock easy and not too cumbersome. Purchasing extra refrigerators will incur more effort to document temperatures, and will take up more office space, so generally it is easier to have one large unit instead of two smaller ones. The only caveat with that is you then run the risk of what to do if you have just one unit and it suddenly fails.
Question: What are the consequences of not managing your vaccine inventory properly?
Answer: All temperature excursions should be immediately reported and discussed with the manufacturers for private stock and with your VFC (Vaccines for Children) Program for VFC stock. Vaccines can often handle warm temperatures safely, but cannot be allowed to be exposed to freezing temperatures at all. If a vaccine if frozen, even briefly, it should be considered worthless. And there is no visual test you can do to determine if a vaccine has been frozen. With Private Stock, the pediatrician can wait until the expiration date has passed and then send it to the manufacturer for replacement at no cost. For VFC vaccine that has not been stored properly, the VFC Inspectors can declare it 'unavoidable' and you are not liable for replacement, or they can decide the spoilage was due to gross negligence and the physician can be expected to replace dose for dose at great expense to the practice.
Question: Let's talk logistics. What is the cost of a vaccine refrigerator? Do you need to purchase other equipment, such as a backup power source?
Answer: Cost for vaccine refrigerators is variable, usually between $2500 - $8000 based on the size and the manufacturer. Shipping can cost $800 or more. When ordering, always specify 'inside delivery' so the refrigerator is not left in the parking lot by the shipper. I prefer vaccine refrigerators that are more wide than deep. It is harder to arrange the different vaccines in a narrow unit because with those, you have to put several different vaccine types in one row. Thermo-Fisher is a top-tier manufacturer, and American Biotech is attractive to those on a tight budget. You can ask your usual supply reps for quotes, and see if you can get them to offer you a competitive price. Refrigerators can sometimes be found online, but pay attention to delivery times. It is not unusual for it to take 6-8 weeks to arrive. In order to prepare for power outages, I do have automatic generators at each office and recommend that others to do if able.
Additional Resources for Vaccine Storage Information
Dr. Barden has other single topics discussed here: SOAPM Vaccine Storage and Handling Resources
A recent article by another PCC client, Dr. Robin Warner, was published by the American Academy of Pediatrics (AAP): CDC changes vaccine storage requirements for all VFC providers.
Centers for Disease Control and Prevention (CDC): Vaccine Storage and Handling Toolkit
National Institute of Standards and Technology (NIST): Vaccine Storage