Results
Patient Care Follow-up Costs
Fifty-two patients with mean age of 9.6 years (range: 2 months to 19 years) were identified as having been exposed to measles at the pediatric clinic. Of these, 34 (65%) were already fully vaccinated; 18 (35%) were aged <12 months and unvaccinated. Five patients (10%) were aged <6 months and were referred to an ED to receive IVIG (Fig. 1) because it was unavailable at the clinic. Thirteen (25%) exposed infants aged 6–11 months were identified and vaccinated ≤72 hours after exposure at the pediatric clinic. The pediatric clinic has a specific area of the clinic dedicated to vaccinations, and these 13 patients did not need an additional visit with the physician before vaccination. However, the clinic did not charge the families the standard fee for vaccine administration, which is typically reimbursed at $28.80 per patient, amounting to a total loss of $374.40.
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Figure 1.
Post-exposure response for patients and employees exposed to measles.
Investigation Costs
Four employees spent 23 hours identifying and contacting exposed patients and caretakers, costing $1056 in employee wages. Two employees spent another 5 hours identifying and contacting exposed employees, costing $203 in employee wages. Additionally, 2 employees spent 6 hours in consultation with the local public health department determining a plan of action, costing $352 in employee wages. During the initial investigation, 2 employees worked overtime to promptly identify and contact exposed persons, costing the pediatric clinic $242 in employee overtime wages. Furthermore, 1 health care worker spent 1.5 hours on the telephone responding to employee and patient concerns regarding the measles exposure that cost $107 in employee wages. The total cost of employee wages to the clinic was $1961.
Employee Follow-up Costs
Ten employees at the pediatric clinic were exposed to measles. One employee had written documentation of 2 doses of MMR vaccine, and 9 required measles titers to determine their immune status and to avoid being excluded from work. Measles titers were obtained at an off-site laboratory and paid for by the pediatric clinic at a total cost of $2704. Five employees (50%), who were either born before 1957 or who had 1 documented previous dose of MMR vaccine, received a dose of MMR vaccine at the pediatric clinic. The clinic spent $616 to acquire adult MMR vaccines for staff. Less than 1 hour was spent vaccinating these staff; employee time spent administering vaccine was not calculated. The total amount the pediatric clinic spent responding to employee exposures was $3320. Titer results demonstrated serologic evidence of immunity among all 9 tested employees. No employees were furloughed in response to the measles exposure.
Other Costs
Because of the unique patient demographics in a pediatric clinic, other costs were incurred as a result of this measles exposure that, in this case, were not paid for by the pediatric clinic but in other situations might be billed to the clinic. All 13 patients who received an outbreak-related MMR vaccine were aged <12 months but will still require 2 subsequent lifetime doses of MMR vaccine. Thus, vaccine administered in response to the measles exposure would be an excess cost to the health care system. In Washington State, all childhood vaccines are paid for through the state vaccination program. However, the private-sector cost that a pediatric clinic elsewhere would pay for 1 MMR vaccine is $56.14, which amounts to a total cost of $730 in extra doses of MMR vaccine not counting toward the recommended 2-dose series.
All of our patients requiring IVIG at an ED had private insurance plans that covered the visit costs. The minimum charge for a visit to the ED at the local hospital is $600 for these infants who would have been billed for a brief encounter with a physician. In addition, the minimum charge for intravenous line placement with medication administration is $367, and the charge for the IVIG medication is $480. IVIG is charged according to number of bottles used; the smallest bottle stocked at the hospital contains 3 g of medication, which would be enough to treat infants weighing ≤7.5 kg (recommended dose of 400 mg/kg body weight). Thus, the minimum charge to insurance companies is $1447 per infant. The actual cost of treatment on the basis of the urban cost-to-charge ratio in Washington State of $0.313 would be $452.91 per infant. In the case of uninsured children, the charge of $1447 per infant would be billed to the caretakers or to the pediatric clinic. The minimum total charge for the 5 infants visiting the local ED would be $7235; CMS in an urban Washington State hospital would reimburse a total cost of $2265.
Total Costs
Overall, 122 people were exposed to measles in the pediatric clinic, costing the clinic $5655, the health insurance system at least $2265 and the Washington Vaccine Program $730. The total cost to the health care system was $8650 (Table 1). Approximately 60% of clinic's costs were attributed to assessing measles immunity status among exposed employees, and the remaining 40% was the cost of identifying and treating exposed infants aged <12 months.