Jillian Shelin was baffled.
When taking her children to receive their regularly scheduled immunizations, as well as a pair of routine flu vaccinations, she was told the clinic was now adding a $30 surcharge per shot -- on top of the couple's $25 insurance co-pay.
Because medical assistants recently were barred from administering injections -- flu shots, immunizations and Botox included -- pediatricians are relying on doctors and nurses to take on the load.
Administering injections is a tedious, expensive, time-consuming practice, physicians say. And because time equals money, some Las Vegas doctors are considering compensating by tacking on extra fees.
"I actually refused service, and left the office," Shelin said. "I have loyalty with her (my doctor). I didn't want to walk out."
Her children's pediatrician, Dr. Lisa Glasser of Bright Futures Pediatrics, said her office had considered adding a surcharge to vaccinations but never did.
The incident with the Shelin family was a mix-up, she said. Although Glasser said her office manager told Shelin there would be a surcharge, physicians in the office later decided not to charge patients.
"The discussion came up about trying to cover the expense associated with someone other than medical assistants having to give vaccines, and I think in the panic of yesterday (Wednesday), we had discussed doing something like adding surcharges," Glasser said. "But we did not take any money."
Glasser said her office performed vaccinations and immunizations Wednesday and Thursday and has never added extra fees for any patient.
But because the financial situation is rocky, the office's practices could change "minute by minute."
"Once the H1N1 campaign has started, there's no way we'll be able to do it (administer injections) without medical assistants," Glasser said. "We've considered it (adding a surcharge), but we'd really rather not do that."
She said other options include stopping all vaccinations and sending patients to the health district.
"All options are on the table," she said. "You have to think of all possibilities."
Pediatrician Kenneth Misch said the physicians in his two practices have discussed adding surcharges for injections but haven't made any firm decisions.
Pediatricians have built their business plans on the assumption medical assistants would be working, he said. Reimbursement from the insurance companies for administering injections barely covers the cost of the vaccine.
If a doctor is administering injections instead of a medical assistant, the reimbursement should be different because a doctor's time is more valuable than a medical assistant's, he said.
Hiring nurses to fill the void is another option, but many physicians can't afford the cost, he said. And even if they could, he said, there aren't enough to go around.
"The nursing shortage in town has been around a long time," Misch said.
Carolyn Yucha, dean of the school of nursing at the University of Nevada, Las Vegas, said that two to five years ago, there was definitely a shortage. But since the recession, more nurses that would have retired are staying employed, and recent graduates are having trouble getting jobs.
"Before, where they could have gone to five different hospitals and got jobs, now they may be waiting a couple months, sometimes even six months," Yucha said.
Physicians in private clinics might have better luck finding nurses now, Yucha said, but she understands the financial difficulties.
"If you can find the same person to do a job for less money, you should do that," she said.
Randal Shelin said he and his wife have considered going to the Southern Nevada Health District, which uses doctors and nurses to give injections, and has set fees: $16 for one vaccination and $25 for two or more.
But if the health district becomes overwhelmed, especially when the H1N1 vaccine becomes available in coming weeks, some families might struggle to get the shots they need, he said.
"It's an unintended consequence from the legislation," he said, referring to the emergency rules from the Nevada State Board of Medical Examiners that were voided by a judge earlier this week. "Health practices are being disrupted."
Gov. Jim Gibbons "strongly encouraged" the medical board Thursday to file a motion to reconsider the decision of District Judge Kathleen Delaney, who said the rules could not be put in place because the board violated the open meeting law.
"My office has been flooded with calls from pediatricians who can no longer have their medical assistants administer immunizations, and from parents who are being turned away from their physician's offices," Gibbons said in a statement. "In addition, the first doses of H1N1 are on the way to Nevada as we are entering flu season. We need medical assistants to be able to work with our physicians to provide medical care during this flu season."
The disruption in medical care in the past few days shows that an attempt to get Delaney to reconsider her ruling is justified, he said.
Calls to the medical board seeking comment were not returned Thursday.
Health District spokeswoman Stephanie Bethel said the district hasn't yet felt a large strain from people seeking immunizations and vaccines.
H1N1 vaccines will arrive at the health district by mid-month, she said, and be delivered to the providers who have registered to receive the vaccine.
Bethel said the district is prepared to vaccinate as many people in the community as possible, and if some physicians have to send patients to them, its goal is to handle the excess.
"Whether or not they go to their doctors, or if their doctors aren't vaccinating, I can't say," she said. "But we're preparing here."
Contact reporter Mike Blasky at email@example.com or 702-383-0283.