The Facts

Why does Government want to stop Doctors from delivering flu shots?

The NLMA has learned through Access to Information that government decided to stop paying for physician-delivered flu shots in order to fund the expansion of the HPV program to include males. This is contrary to government’s stated reason for eliminating the MCP fee code for influenza vaccination by physicians – namely, to ensure health care providers are working to their full scope. Physicians wholeheartedly support expanding the HPV vaccination program to include males. However, we do not believe it should funded by reducing access to flu shots.

The Minister of Health says doctors were “extra billing” for flu shots, is this true?

No. The Minister of Health claimed that doctors bill MCP for a patient’s office visit and then bill MCP extra if the patient requests a flu shot. This is not accurate.

Fee-for-service family physicians can provide flu shots in one of two ways: 1) during a flu shot appointment, or 2) during a regular office visit where other medical conditions are discussed. If a patient makes an appointment for the sole purpose of requesting a flu shot, the family physician bills MCP $17.16. If a patient requests a flu shot as part of a regular office visit that also involves addressing other medical issues, the family physician bills MCP $32.20 for the office visit. Physicians have never been permitted to bill for both the office visit and the flu shot at the same time for the same patient. Flu shots administered during regular office visits are, therefore, provided by the family doctor at no cost to MCP.

Why are physicians concerned about patients not getting the flu shot?

Each year, physicians administer flu shots to vulnerable patients who are at risk of developing complications from influenza. This includes everyone from the frail elderly to very young children. It includes pregnant women and those with chronic health conditions like cardiovascular diseases, respiratory illnesses, or other immune-compromising conditions.

Physicians in the province are concerned that if the government’s plan goes ahead, fewer people will get the flu shot and more cases of influenza will occur during the next flu season.

During the 2016-2017 flu season, there were 202 hospitalizations, 29 ICU admissions and 13 deaths in Newfoundland and Labrador as a result of influenza. Reducing access for the citizens of Newfoundland and Labrador could have serious health consequences. If vaccination rates are significantly reduced, these numbers could grow.

According to the most recent statistics from Statistics Canada, Newfoundland and Labrador had the second-lowest proportion of people who received the flu vaccine of all provinces and territories in 2014. Therefore, the provincial government should focus on improving influenza vaccination rates rather than reducing the points of access for patients.

Of the 106,177 does of influenza vaccines administered throughout the province last year, 48,131 or nearly half (45%), were administered by physicians. (This number is likely higher as it only takes into account self-reported numbers by clinics.)

The Minister of Health says the same number of flu shots will be available this flu season so why are doctors concerned?

Simply put, availability does not guarantee access. The NLMA is not convinced that the Government of Newfoundland and Labrador has put the necessary resources in place to ensure public health has the capacity to nearly double its number of flu shots to accommodate patients who will no longer be vaccinated by family physicians.

To double the size of the public system in a single year and expect between 39,500 and 44,500 people to switch to a new site is not a credible plan. It is an untested idea that puts patients at risk and will result in increased costs to the system rather than savings.

What will government’s decision mean for patients?

There are more than 360 fee-for-service family doctors in the province who will no longer be paid to provide MCP-covered flu shot-only appointments. Removing these points of access reduces patient choice and makes it more difficult to get a flu shot.

The NLMA supports a strategy where all health professionals do their part to collaboratively increase the flu shot coverage rate. The NLMA supports the critical role of public health nurses and pharmacists in delivering flu shots in a multi-layered system. Dismantling the parallel physician-provided delivery channel is a step backward.

It is not always easy for patients in rural areas to access a community flu shot clinic. Some flu shot clinics offered during last year’s flu season were only available at select sites on certain days and at specific times. We know that in some communities public health flu shot clinics were only offered once for a half-day. In some communities they were not offered at all.

Physicians have also been told by patients that there can be long lineups and wait times for public health flu shot clinics, especially in the metro region. Many elderly patients who lack mobility, transport, and physical stamina to wait in long lineups simply cannot venture out and wait. They often prefer to book an appointment with their family doctor for easier access. This could also be said for families with young children.

Many doctor’s offices also hold special clinics after hours or on weekends to accommodate the volume of people seeking flu shots.

As a preventative service, some doctor’s offices also call their patients to schedule a flu shot appointment. They also remind many of their vulnerable patients, who are at risk of developing complications, that it is important that they get their flu shot. Some patients may never obtain a flu shot without these types of proactive reminders.

Will the government’s decision save the province money?

No. In 2016-2017, MCP was billed $496,233 for physician-administered flu shots to 29,352 people who booked flu shot-only appointments. At least 18,779 others were vaccinated by physicians at no cost to MCP because they were delivered as part of regular office visits. (This number is likely higher as it only accounts for self-reported tallies, and may be as high as 33,000 vaccines administered at no cost to MCP given that more than 62,000 vaccines were distributed to doctors last year.)

Government intends to use the savings from cutting physician-delivered flu shots to fund the expansion of the HPV program to include males, which will cost approximately $360,000. The provincial government has not presented the public with any cost analysis. However, NLMA has learned through Access to Information that public health flu shot clinics provided through Eastern Health are already operating at a deficit and that $227,000 is needed in Eastern Health alone to accommodate patients who will no longer be vaccinated by physicians. This does not take into account costs for the other regional health authorities (RHAs).

To accommodate this increased demand, RHAs will have to increase their capacity to deliver public flu shot clinics if the province intends to maintain its current vaccination rate. This will require more community flu shot clinics open for longer hours and staffed by more providers in order to cope with the thousands of additional patients.

Documents obtained through Access to Information also show that it costs Eastern Health roughly $9 per influenza immunization. If this cost is consistent across other RHAs, it could cost between $355,000 and $400,000 to accommodate the 39,500 to 44,500 patients that will be displaced from physicians this year. This does not include the $360,000 needed to fund the expansion of the HPV program.

If government’s decision results in fewer patients being vaccinated for influenza, we will also see an increase in ER visits, hospitalizations and ICU admissions, which will add additional costs to the system. In fact, the best estimate of doctors is that just 30-40 percent of patients will complete the transfer to the public health clinics. If this low rate of transfer occurs, about 20,000 fewer people will receive their flu shot this year. The effects that may potentially be seen in the health of patients could lead to more health care dollars being spent in treating influenza instead of being spent on prevention.

Furthermore, the time that physicians normally set aside for flu shot appointments will simply be used to see other patients who are waiting for their medical appointments. Doctors will be compensated from MCP for these services, so it is not clear to us how this decision saves money.

Are doctors opposed to flu shots being given by public health nurses or pharmacists?

Absolutely not. Physicians recognize that the immunization services provided at community health clinics and pharmacies are vital, but dismantling the parallel physician-provided delivery channel is a step backward. We should be promoting more access to flu shots, not less.

The government will say that it can maintain current vaccination rates, which are already low, by increasing the capacity of public health flu shot clinics. This is an untested idea. We are not confident that extra processes and resources have been put in place to accommodate the thousands of new patients. This decision may ultimately result in more costs to the system, reduced access for patients and higher risk of influenza related illness.

Did the provincial government consult physicians before un-insuring flu shots from MCP?

No. The provincial government did not consult with the NLMA prior to its decision despite the significance of the issue, the potential impact on patients and the established mechanisms for consultation.

Are doctors concerned about the flu shot because they are worried they will lose money?

No. Physicians are genuinely concerned about population health if a flu shot delivery channel that vaccinates more than 48,000 patients each year is suddenly removed. Furthermore, the time that physicians normally set aside for flu shot appointments will simply be used to see other patients who are waiting for their medical appointments. Doctors will be compensated from MCP for these services, therefore, it is unlikely their incomes will be impacted.

The doctor-patient relationship is the most important bond in medicine. Doctors will only entrust the care of their patient to another provider if the certainty of care is assured. There are too many unknowns with government’s proposals and doctors do not have confidence that the best interests of their patients are foremost.

Why would patients prefer to receive their flu shots from their family doctor?

For some patients, a flu shot clinic may mean additional travel. Some patients do not like the wait times and the more crowded clinics. Others simply prefer to use the same provider they have had for many years. Trust and confidence will exist with ongoing relationships with the same nurse or doctor or pharmacist, and it is unwise to break those relationships.

In May 2017, the NLMA commissioned Corporate Research Associates to poll a representative sample of Newfoundlanders and Labradorians on their attitudes towards the flu shot. When asked where they would most prefer to receive the flu shot, participants reported the following:

  • 46% said a doctor’s office
  • 33% said a public health clinic
  • 12% said a pharmacy
  • 8% had no preference
  • 2% did not know

Of those who said they preferred to receive the flu shot at a doctor’s office, the top reasons cited by those surveyed was their established relationship with their provider, followed by better accessibility.

If government is not paying doctors for flu shot-only visits, can doctors charge patients privately for this service?

The Government documents we have seen suggest this is the case.  Normally, if a fee code is removed from MCP, and thus not insured, the service can be undertaken privately.  The NLMA believes this is a step backward.  Flu shots should continue to be insured by government when provided in physician offices.  Government should not be encouraging the privatization of such a basic public health service.