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New Hampshire is joining a growing national trend in allowing pharmacists to give more vaccinations than annual flu shots -- but doctors oppose the changes in what appears to be a turf war over a profitable aspect of medical care.
A new state law lets trained pharmacists give vaccinations for a bacterial form of pneumonia that can be deadly and for shingles, a painful reappearance of latent chicken pox virus that affects the nerve roots and can produce a blistering rash.
The federal Centers for Disease Control and Prevention says the trend to let pharmacists give vaccines has grown from 22 states allowing flu shots in 1999 to all 50 in 2009. All but a handful of states now allow other vaccines as well.
State Rep. Frank Case, a pharmacist and one of the law's sponsors, said New Hampshire's law will provide greater public access to vaccines but he acknowledges the move effectively sparked a turf war with the state medical society, which wanted more control.
People getting vaccines from pharmacists would not be making a costly visit to their physician. For many people with health insurance, vaccinations are now fully covered as preventive care under the new Affordable Care Act, without copays.
At issue, say doctors, are prescriptions from doctors and notifications to doctors after the vaccines are given.
The New Hampshire law does not require people to first get a doctor's prescription for the immunizations. And pharmacists would be required to report giving the shot to a patient's doctor only if the person tells the pharmacist he has a doctor.
"What they (the physicians) wanted was to have the person go to the doctor and get a prescription and then get a shot," Case said.
Dr. Travis Harker, a family doctor and vice president of the New Hampshire Medical Society, said the society wanted better coordination of care by requiring a doctor's prescription and notice of the shot being given to include in the person's medical record.
"The medical society feels pharmacists are competent to give shots, but we do not want patients confused about what shots they need or to be convinced by a strong marketing campaign to get a shot they do not need," said Harker.
Harker said the emphasis should be on maintaining a medical home for the patient.
But Case took issue with that. "This medical home thing doesn't mean a lot to me as a pharmacist," responded Case, a Nottingham Republican. "I don't see how patients can have a total medical home without including a pharmacist."
Kathleen Dachille, director of the eastern region of the Public Health Law Network, said the turf war poses interesting questions for lawmakers since public access to preventive medicine is as valid as doctors' wanting to maintain patients' records. But she said many people don't have a primary care doctor to begin with.
"The doctors' perspective is valid, but not what's going on in the real world," she said.
She added that someone may get vaccinated while "going into a CVS to pick up aspirin. How often do you just walk into your doctor's office?"
Dachille said doctors make money by giving shots.
"They make money when you come in and get a vaccination, even if you only pay a copay," she said.
Harker said the society is concerned with patient health, not the money.
"It's not just a slam-dunk like the flu shot. Almost everyone should get a flu shot. The others are more nuanced," he said.
So far, national vaccination rates are poor for shingles -- about 7 percent for adults over age 60 who are at greatest risk of getting the disease, according to a 2008 National Health Interview Survey. About 60 percent of those over age 65 have gotten the pneumococcal shot.
The CDC said Merck & Co., which manufactures both vaccines, sells a single dose of shingles vaccine wholesale for $161.50, while the pneumococcal vaccine is $48.97. The shingles vaccine can cost more than $200 for uninsured people paying cash.
The Affordable Care Act requires health plans to cover a range of preventive services without copayments, but the requirement does not apply to all plans, said Richard Sorian, a spokesman for the federal Health and Human Services Department.
"For many people with health insurance, the shots will be covered at no extra cost to them if the pharmacist is in their plan's network," he said. He advised that people check their plans beforehand.
The pneumococcal vaccine requires no special storage but Zostavax, the shingles vaccine, must be kept frozen until 30 minutes before it is thawed, prepared and injected. Not all pharmacies or doctors have freezers capable of storing the vaccine.
Ron Petrin of Bedford, president of the New Hampshire Pharmacy Board, said his freezer cost $8,000, an expense that would make it hard for independent pharmacies to afford to offer the service.
Dr. Eddy Bresnitz, Merck Global Medical Affairs director for adult vaccines, said Merck does not recommend getting a doctor's prescription, taking it to a pharmacy to pick up the vaccine and then "brown-bagging" it back to the doctor's office to be administered.
"The more practical approach is for the pharmacist to give it," he said.
Zostavax, the shingles vaccine licensed in 2006, is in short supply with up to a three-month wait for delivery, which Bresnitz said Merck is working to shorten with increased supply. He said 44 states allow pharmacists to administer the vaccine.
New Hampshire law requires pharmacists to undergo training in giving immunizations and to carry $1 million in liability insurance.
Pharmacy chains like CVS, Rite Aid and Walgreens all say their pharmacists will administer the pneumococcal shot in New Hampshire, but CVS said it will arrange to deliver Zostavax to a person's doctor for administration. Walgreens said select stores will administer Zostavax initially while Rite Aid said all its stores will give both vaccinations.
New Hampshire has about 30 independents, said Rick Newman, lobbyist for the New Hampshire Independent Pharmacist Association.
"It's not going to be available at every corner drug store" he cautions consumers.