Vaccine Delivery, Financing, and Demand Subgroup

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Vaccine Delivery, Financing, and Demand Subgroup
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Vaccine Delivery, Financing, and Demand Subgroup

• Fernando Guerra (chair)
• Georges Peter
• William Schaffner
• Ray Strikas
• Dan Fishbein
• Mark Messonnier
• Sarah Landry
• Kari Sapsis

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Question 1

• Are the current private/public programs for adult
  immunization adequate?

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Answer 1
HP 2010 Targets
Age gt 64
Age lt 65 in target group
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Question 2

• What changes should be made to enhance acceptance
  and promote demand for influenza vaccine by the
  public and health officials?

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Answer 2

• Priority must be given to remedying the cost and
  inconvenience of immunization. We must
• Change societal attitudes to greatly increase
  individuals and providers willingness to pay for
  preventive services AND/OR
• Develop a Vaccines for Adults program which
  greatly reduces costs to the patient and provider

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Answer 2

• Messages to the immunization community must
  emphasize recognized cost-effective ways to
  increase immunization coverage
• Redefine the concept of the medical home as it
  regards preventive services.
• The medical home for a flu shot is anywhere you
  get it
• Pharmacies and other alternative sites are
  essential to accessible and quality adult
  immunization services

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Answer 2

• Priorities should shift from documenting
  disparities to assessing interventions strategies
  ..that separate the contribution of the patient,
  provider, and institution
• Unequal
  Treatment
• Institute of Medicine 2002

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Questions 3

• What changes could be made to strengthen this
  programmatic infrastructure?

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Answer 3

• Make influenza vaccination a less expensive
  prevention strategy for the patient and provider
• Create/enhance/sustain comprehensive vaccination
  programs for adults
• Assure proper translation of ACIP standards into
  laws and managed care contracts
• Improve insurance coverage through model
  legislation and tailored improvements in existing
  laws, i.e. develop a Vaccines for Adults
  Program

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Critical Issues

• What is financing?
• Who finances vaccination?
• What is the effect of financing on delivery?
• Are there other ways to increase delivery?

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What Is Financing?

• Raising revenue to pay for a good or service
• Module 1 Health Sector Reform and Sustainable
  Financing
• World Bank

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Who Finances Vaccination?

• Manufacturers and distributors
• Patients
• Out of pocket expenses
• Opportunity cost
• Providers
• Overhead and communication
• Screening and assessment
• Vaccine and administration

• Employers
• Insurer
• Reimbursement
• Overhead and communication

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Who Finances Vaccination? Patient Costs
Total time in office while obtaining shot only
15-20 min (Fontanesi) Based on average wages
(BLS, Molinari) Estimated time 15-20 min X 2
6-8 (BLS, Molinari) No out of pocket cost
to full pay without insurance Estimated for
public transportation or mileage and
parking Estimated 1-7 for expenses
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Who Finances Vaccination? Provider Costs
Shot only clinics appointments (Coleman).
May be lower due to economies of scale when a
patient comes in for several services. Time and
wages of staff with direct patient contact E.g.
overhead and back office costs (rent, pulling
charts, billing)
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Who Finances VaccinationI Health Insurer
Coverage - Beneficiary Level
Davis M Because 5 of Medicare patients dont
have outpatient benefits (Part A) Percent of
claims in which both vaccine and admin paid (N
Molinari, Medstat Marketscan 2002 data (rounded)
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Who Finances Vaccination?II Reimbursement by
Insurer
Source N. Molinari, Medstat Marketscan 2002
data (rounded) Physicians are collecting some
funds from the patient, possibly in anticipation
of underpayment by insurers
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Who Finances Vaccination?III. Medicaid Coverage
and Reimbursement

• All states except Louisiana and Alaska cover some
  or all vaccines for adults
• Only two states New York and California have a
  comprehensive program that
• covers all ACIP recommendations
• permits only nominal co-pay
• provides vaccine replacement
• allows separate billing of administration fee
• All other states are intermediate

Source Rosenbaum S
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Who Finances Vaccination?Summary
15 time/travel costs patient pays 20 (no
insurance) 5 (copay), 0 (full) Adapted from
Coleman Medicare Private insurer
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What is the Effect of Financing on Delivery?
Decreasing Time It Takes to Get Vaccinated
Percent Vaccinated
HP 2010 Target
When Vaccinated
Source Fishbein
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What is the Effect of Financing on
Delivery?Small Co-payments
Percent Vaccinated
HP 2010 Target
When Vaccinated
Source Fishbein NVPO grant
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Are There Other Ways to Increase Demand and
Improve Delivery?What the Literature Says

• Reorganize preventive service delivery
• Prevention clinics, prevention visits, designate
  non physician staff for prevention activities
  (standing orders)
• Provide patient financial incentives
• Institute provider/patient reminder-recall
• In conjunction with above
• Education give the patient a salient reason to
  get vaccinated
• Registries and hand held records to decrease
  unnecessary re-immunization

Adapted from Stone (2002) and Shefer (1999)
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How Can Using Communication Principles Increase
Demand?

• A good intervention
• Segments the audience
• Focuses on targets of opportunity
• Promotes benefits to the target audience
• Reduces barriers from the target audiences
  viewpoint
• Is based on evidence
• Formative research

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Coverage for adult immunization is a fig leaf,
incomplete, focused on specific areas
A physician trying to finance community-wide
adult immunization program

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V F A
Vaccines for Adults
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References

• Cassidy W (et al). Can Emergency Department
  Visits Be Opportunities To Vaccinate Adults? A
  Pilot Study In an Urban Public Hospital. NIC
  2004 (abstract 5178)
• Coleman M (et al) Estimating Medical Practice
  Expenses from Adult Influenza Vaccinations
• Davis M (et al). Adult Vaccine Benefit Coverage
  in Employer-Sponsored Health Plans. National
  Immunization Conference 2004 (abstract 4906) and
  unpublished data
• Fishbein D (et al). Adult Vaccination in
  Emergency Rooms A Shot at Decreasing Health
  Disparities in the United States? NIC 2004
  (abstract 5485)
• Fontanesi J (et al). Operational conditions
  affecting the vaccination of older adults. Am J
  Prev Med. 2004 May26(4)265-70 and unpublished
  data
• McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J,
  DeCristofaro A et al. The quality of health care
  delivered to adults in the United States. N Engl
  J Med 2003 348(26)2635-2645.
• Molinari NA. Medstat Marketscan data
  (unpublished)
• Rosenbaum S. State Immunization Coverage
  Standards Medicaid and Private Health Insurance
  NIC 2004 and www.gwhealthpolicy.org/immunization
• Stone EG, Morton SC, Hulscher ME, Maglione MA,
  Roth EA, Grimshaw JM et al. Interventions that
  increase use of adult immunization and cancer
  screening services a meta-analysis. Ann Intern
  Med 2002 136(9)641-651.
• Yarnall KS, Pollak KI, Ostbye T, Krause KM,
  Michener JL. Primary care is there enough time
  for prevention? Am J Public Health 2003
  93(4)635-641.

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Adherence to Quality Indicators, According to Mode
McGlynn, E. A. et al. N Engl J Med
20033482635-2645
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Are There Other Ways to Increase Demand and
Delivery?What the Literature Says

• In the United States, delivery of preventive care
  in general and immunization in particular is not
  bad
• Performance was similar for preventive care
  (55), acute care (54), and care for chronic
  conditions (56)
• Immunizations were delivered in at a greater
  frequency (66) than many other recommended
  preventive service
• McGlynn, The Quality of Health Care Delivered
  to Adults in the US, 2003)
• Providers lack sufficient time to further
  increase preventive services