Rodney E. Rohde, PhD, MS, SM (ASCP) CM, SVCM, MBCM, FACSc: We’ve talked about some of these considerations when selecting vaccine formulations, whether it’s the patient population, age, chronic disease, complications, and patient preference. I’d like to ask Dr [Adam] Welch, with his background, and you can all chime in here, what criteria should be considered when choosing a specific high-dose flu vaccine formulation for immunization.

Adam C. Welch, PharmD, MBA, FAPhA: First, it’s important to mention that the ACIP [Advisory Committee on Immunization Practices] says preferentially you should use high-dose, you should use adjuvanted or recombinant, or recombinant. Any of those 3 would be preferentially recommended. They do not say which one is better than the others. And quite frankly, the evidence head-to-head comparing those 3 is lacking. We just don’t know. We have a lot of evidence comparing them individually to placebo, or a lot of observational studies, but you can’t draw a lot of conclusions from that. Preferentially, they want 1 of those 3. Now, which one you pick is up to you. As a pharmacist, you would want to look at the FDA indication. The recombinant can be used for [ages] 18 and older, whereas the high dose and the adjuvant are for [ages] 65 and older. The CDC further says if a patient is here and they’re likely not going to be back to the health care system and you don’t have 1 of those 3 preferential products, get them a standard dose, get them something. Something is better than nothing. The 3 preferential are better than the standard options that are there. Now, I think that the issue with this is, and [Dr McDonough], you can comment on this, community pharmacists need to make these decisions several months in advance. They have to order their vaccines in anticipation of the upcoming flu season. So how do you know what patient demographics, what clientele you’re going to be seeing?

Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: Yes, and the thing I’ll tell you too is that you run into shortages. We did run into that with high dose; we couldn’t get access to high dose. So now we’re like, OK, we’ve got to use whatever else we can get access to. So yes, we have to make decisions way in advance. And when I talk about the flu vaccine and we talk about the World Health Organization and it’s just continuous throughout the year, the same is true within community pharmacy because you’re prebooking vaccines way in advance. You’re trying to make determinations about, how many we are going to need? We try to anticipate, maybe we need a higher percentage this year. Do we want to have a little bit of everything? Because some patients may say, “Well, I want this, or I have an egg allergy, so I need to get this.” We’re always looking at having a variety, but you also have to consider not overbooking. It’s always this business function as well. But it’s up to us to make sure we’re going out there and not only generating interest within the public but also, as we talked about, meeting the patients where they’re at. We do a lot of remote clinics; we are booking those at this time right now for the fall. There’s a lot of planning that goes into this, and it starts as soon as we are done with the current flu season. We’re going right into the next flu season and doing some of this stuff. It’s a lot of work and a lot of effort, and we don’t always get it right. But then again, World Health Organization doesn’t always get it right either.

Adam C. Welch, PharmD, MBA, FAPhA: I think there’s another financial piece to this that we also have to talk about. Many years ago, there was one administration fee for whatever vaccine you would choose. I think a lot of providers chose the least expensive inventory option to put in. Now there are different codes for each brand of influenza vaccine. So the one you pick may cost more than another one, but the compensation, at least from a Medicare standpoint, will be comparable.

Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: Absolutely.

Chad Worz, PharmD, BCGP, FASCP: I think that’s important because there were places where the push to give flu vaccine superseded the ability of the system or the practitioner to bill for it. So to them, like in a nursing home, sometimes it was a loss leader. We have to do this, [but] the billing’s complicated, so I’m going to pick the cheapest thing I can find. And making sure that we educate people on how Medicare reimburses, that they do cover the cost of these vaccines, and that the administration fee is similar across the different types of vaccine is important because then it gives them the comfort of getting reimbursed for this. I’m not giving you a $100-and-something vaccine and not getting reimbursed for it. So those things are important to tease out.

Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: I think it’s important too from a community pharmacy perspective that...the patient always comes first, so I want to make sure I make that very clear. But vaccinations are for the public good. We’ve got to make sure our community is being vaccinated appropriately. It’s such a low-hanging fruit for community pharmacists because this is not where you have to take a half hour and you’re sitting down with the patient after they fill out the paperwork, which they can do online now. A lot of our scheduling is done online, so we can predict the flow of patients. But when they come in, it’s maybe 5 minutes that you’re dealing with them or working with them. Then we’re doing an observation, and they’re in and out, and it works pretty efficiently. It’s a great way for pharmacists to provide good to the community, and financially it’s very beneficial.

Rodney E. Rohde, PhD, MS, SM (ASCP) CM, SVCM, MBCM, FACSc: Yes. This is all really good stuff. Even I’m learning, because in the laboratory medicine world, we know that physicians, and this is kind of a similar thing, will sometimes order the test that’s the first one that pops up on a menu.... But this is really good information to understand that this is why you want a relationship with your community pharmacist, or if you’re in the hospital, to have that conversation. Even if you need to talk to that pharmacist and say, “Well, slow down. I’m not sure I understand what’s going on here,” so that you can get that education out there.

Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: [Dr Rohde], I was talking to you earlier, but we have physicians who are like pharmacies, where they’re trying to disrupt and do something different because of reimbursement issues. And we’ve got a concierge physician who stepped out of her internal medicine practice with the university to start her [own] practice. She came to us because she’s looking at how she can get patients vaccinated. That leads to other conversations about how we can provide a pharmacy benefit to her patients as well, which might be a different model of that. I think this is exciting about what’s happening in health care and disruption, I know about disruption.

Rodney E. Rohde, PhD, MS, SM (ASCP) CM, SVCM, MBCM, FACSc: Disruption and change agents make things better. That’s always good.

Transcript edited for clarity.