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

Subgroup Subgroup

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

Fernando Guerra (chair)Fernando Guerra (chair)Georges PeterGeorges PeterWilliam SchaffnerWilliam SchaffnerRay StrikasRay StrikasDan FishbeinDan FishbeinMark MessonnierMark MessonnierSarah LandrySarah LandryKari SapsisKari Sapsis

Question 1 Question 1

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

Answer 1Answer 1

0

20

40

60

80

100

1988 1990 1992 1994 1996 1998 2000 2002

Influenza Season

Per

cent

Vac

cina

ted

>64 Yrs.

50-64 High Risk

50-64 All

18-49 High Risk

HP 2010 HP 2010 TargetsTargets

Age < 65 in target

group

Age > 64

Question 2Question 2

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

Answer 2Answer 2

Priority must be given to remedying the Priority must be given to remedying the cost and inconvenience of immunization. cost and inconvenience of immunization. We must:We must:– Change societal attitudes to greatly increase Change societal attitudes to greatly increase

individuals and providers willingness to pay individuals and providers willingness to pay for preventive services for preventive services AND/ORAND/OR

– Develop a “Vaccines for Adults” program Develop a “Vaccines for Adults” program which greatly reduces costs to the patient which greatly reduces costs to the patient and providerand provider

Answer 2Answer 2

Messages to the immunization community must Messages to the immunization community must emphasize recognized cost-effective ways to emphasize recognized cost-effective ways to increase immunization coverage increase immunization coverage

Redefine the concept of the medical home as it Redefine the concept of the medical home as it regards preventive services.regards preventive services.– ““The The medical homemedical home for a flu shot is anywhere you for a flu shot is anywhere you

get it”get it”

Pharmacies and other alternative sites are Pharmacies and other alternative sites are essential to accessible and quality adult essential to accessible and quality adult immunization servicesimmunization services

Answer 2Answer 2

““Priorities should shift from documenting Priorities should shift from documenting disparities to assessing interventions disparities to assessing interventions strategies …..that separate the strategies …..that separate the contribution of the patient, provider, and contribution of the patient, provider, and institutioninstitution

““Unequal Treatment”Unequal Treatment”Institute of Medicine 2002Institute of Medicine 2002

Questions 3 Questions 3

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

Answer 3Answer 3

Make influenza vaccination a less expensive Make influenza vaccination a less expensive prevention strategy for the patient and providerprevention strategy for the patient and providerCreate/enhance/sustain comprehensive Create/enhance/sustain comprehensive vaccination programs for adultsvaccination programs for adultsAssure proper translation of ACIP standards into Assure proper translation of ACIP standards into laws and managed care contractslaws and managed care contractsImprove insurance coverage through model Improve insurance coverage through model legislation and tailored improvements in existing legislation and tailored improvements in existing laws, i.e. develop a “Vaccines for Adults laws, i.e. develop a “Vaccines for Adults Program”Program”

Critical IssuesCritical Issues

What is financing?What is financing?

Who finances vaccination?Who finances vaccination?

What is the effect of financing on delivery?What is the effect of financing on delivery?

Are there other ways to increase delivery?Are there other ways to increase delivery?

What Is Financing?What Is Financing?

Raising revenue to pay for a good or Raising revenue to pay for a good or serviceservice

Module 1: Health Sector Reform and Sustainable FinancingModule 1: Health Sector Reform and Sustainable Financing

World BankWorld Bank

Who Finances Vaccination?Who Finances Vaccination?

Manufacturers and Manufacturers and distributorsdistributorsPatientsPatients– Out of pocket expensesOut of pocket expenses– Opportunity costOpportunity cost

ProvidersProviders– Overhead and Overhead and

communicationcommunication– Screening and assessmentScreening and assessment– Vaccine and administrationVaccine and administration

EmployersEmployers

InsurerInsurer– ReimbursementReimbursement– Overhead and Overhead and

communicationcommunication

Who Finances Vaccination?Who Finances Vaccination? Patient CostsPatient Costs

ComponentComponent Time (min)Time (min) CostCost

Opportunity costOpportunity cost

Time in office*Time in office* 15-2015-20 $3 - $4$3 - $4††

Time before/afterTime before/after‡ 15-2015-20 $6 - $8$6 - $8

Out-of-pocket costsOut-of-pocket costs

Vaccine and administration¶ $0 - $20$0 - $20

Travel costs** $1 - $7$1 - $7

Total patient costTotal patient cost 30-4030-40 $10-$39$10-$39* 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

ComponentComponent

TimeTime

(min)(min)

CostCost

(2003 $)(2003 $)

Observed laborObserved labor†† 5-115-11 $1 - $8$1 - $8

Unobserved labor & Unobserved labor & costscosts‡

3838 $12 - $33$12 - $33

VaccineVaccine ---- $7 - $9$7 - $9

Total provider costTotal provider cost 43-4943-49 $20 - $50$20 - $50

Who Finances Vaccination? Who Finances Vaccination? Provider Costs*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)

Who Finances VaccinationWho Finances VaccinationI: Health Insurer Coverage - Beneficiary LevelI: Health Insurer Coverage - Beneficiary Level

* Davis M† Because 5% of Medicare patients don’t have outpatient benefits (Part A)‡ Percent of claims in which both vaccine and admin paid (N Molinari, Medstat Marketscan 2002 data (rounded)

VaccinationVaccination

EmployerEmployer

Sponsored*Sponsored*

MedicareMedicare

CoveredCovered 80-84%80-84% 95%95%††

ReimbursedReimbursed 57%57% 83%83%‡‡

ComponentComponent Non-Non-MedicareMedicare

MedicareMedicare

Paid by insurerPaid by insurer $12.34$12.34 $ $ 4.814.81

Co-pay, deductibleCo-pay, deductible 1.501.50 2.902.90††

Coordination of benefitCoordination of benefit 0.170.17 2.032.03

TotalTotal $14.01$14.01 $9.74$9.74

Who Finances Vaccination?Who Finances Vaccination?II: II: Reimbursement by InsurerReimbursement 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

All states except Louisiana and Alaska cover All states except Louisiana and Alaska cover some or all vaccines for adultssome or all vaccines for adultsOnly two states New York and California have a Only two states New York and California have a comprehensive program that comprehensive program that – covers all ACIP recommendationscovers all ACIP recommendations– permits only nominal co-paypermits only nominal co-pay– provides vaccine replacementprovides vaccine replacement– allows separate billing of administration feeallows separate billing of administration fee

All other states are intermediateAll other states are intermediate

Who Finances Vaccination?Who Finances Vaccination?III. Medicaid Coverage and Reimbursement*III. Medicaid Coverage and Reimbursement*

* Source: Rosenbaum S

Who Finances Vaccination?Who Finances Vaccination?SummarySummary

Insurance (reimbursement)Insurance (reimbursement)

NoneNone PartialPartial Full*Full*

Patient*Patient* $35$35 $20$20 $15$15

Provider (cost)Provider (cost)††

mass clinic ($20)mass clinic ($20) $0$0 $9$9 $6$6

appointment ($50)appointment ($50) $20$20 $29$29 $26$26

InsurerInsurer $0$0 $6$6‡‡ $14**$14**

TotalTotal ------------------$35 - $55$35 - $55------------------* $15 time/travel costs; patient pays $20 (no insurance) $5 (copay), $0 (full)† Adapted from Coleman‡ Medicare** Private insurer

0%

25%

50%

75%

EDClin

cED

Clinic ED

Clinc

Duringstudy

Beforestudy

Influenza Pneumococcal Hepatitis B P<0.00001 P=0.045 P=0.09

What is the Effect of Financing on Delivery? What is the Effect of Financing on Delivery? Decreasing Time It Takes to Get VaccinatedDecreasing Time It Takes to Get Vaccinated

HP 2010 TargetHP 2010 Target

PercentVaccinated

WhenVaccinated

Source: Fishbein

0%

25%

50%

75%

$0 $5 $10 $0 $5 $10 $0 $5 $10

DuringVisit

BeforeVisit

Influenza Pneumococcal Hepatitis B P<0.001 P<0.001 P<0.01

What is the Effect of Financing on Delivery?What is the Effect of Financing on Delivery?Small Co-paymentsSmall Co-payments

PercentVaccinated

WhenVaccinated

HP 2010 TargetHP 2010 Target

Source: FishbeinNVPO grant

Are There Other Ways Are There Other Ways to Increase Demand and Improve to Increase Demand and Improve

Delivery?Delivery?What the Literature SaysWhat the Literature Says

Reorganize preventive service deliveryReorganize preventive service delivery– Prevention clinics, prevention visits, designate non Prevention clinics, prevention visits, designate non

physician staff for prevention activities (standing physician staff for prevention activities (standing orders)orders)

Provide patient financial incentivesProvide patient financial incentivesInstitute provider/patient reminder-recallInstitute provider/patient reminder-recallIn conjunction with aboveIn conjunction with above– Education: give the patient a salient reason to get Education: give the patient a salient reason to get

vaccinatedvaccinated– Registries and hand held records to decrease unnecessary Registries and hand held records to decrease unnecessary

re-immunization re-immunization

Adapted from Stone (2002) and Shefer (1999)

How Can Using Communication How Can Using Communication Principles Increase Demand?Principles Increase Demand?

A good interventionA good intervention– Segments the audienceSegments the audience– Focuses on targets of opportunityFocuses on targets of opportunity– Promotes benefits to the target audiencePromotes benefits to the target audience– Reduces barriers from the target audiences Reduces barriers from the target audiences

viewpointviewpoint– Is based on evidenceIs based on evidence

Formative researchFormative research

A physician trying to finance community-wide adult immunization program

“Coverage for adult immunization is a fig leaf, incomplete, focused on

specific areas”

V F AV F AVaccines for Adults

+

ReferencesReferencesCassidy W (et al). Can Emergency Department Visits Be Opportunities To Vaccinate 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) Adults? A Pilot Study In an Urban Public Hospital. NIC 2004 (abstract 5178) Coleman M (et al) Estimating Medical Practice Expenses from Adult Influenza Coleman M (et al) Estimating Medical Practice Expenses from Adult Influenza

VaccinationsVaccinationsDavis M (et al). Adult Vaccine Benefit Coverage in Employer-Sponsored Health Plans. Davis M (et al). Adult Vaccine Benefit Coverage in Employer-Sponsored Health Plans.

National Immunization Conference 2004 (abstract 4906) and unpublished dataNational Immunization Conference 2004 (abstract 4906) and unpublished dataFishbein D (et al). Adult Vaccination in Emergency Rooms: A Shot at Decreasing Health Fishbein D (et al). Adult Vaccination in Emergency Rooms: A Shot at Decreasing Health

Disparities in the United States? NIC 2004 (abstract 5485)Disparities in the United States? NIC 2004 (abstract 5485)Fontanesi J (et al). Operational conditions affecting the vaccination of older adults. Am J Fontanesi J (et al). Operational conditions affecting the vaccination of older adults. Am J

Prev Med. 2004 May;26(4):265-70 and unpublished data Prev Med. 2004 May;26(4):265-70 and unpublished data McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A et al. The quality of 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; health care delivered to adults in the United States. N Engl J Med 2003; 348(26):2635-2645. 348(26):2635-2645.

Molinari NA. Medstat Marketscan data (unpublished)Molinari NA. Medstat Marketscan data (unpublished)Rosenbaum S. State Immunization Coverage Standards: Medicaid and Private Health Rosenbaum S. State Immunization Coverage Standards: Medicaid and Private Health

Insurance NIC 2004 and Insurance NIC 2004 and www.gwhealthpolicy.org/immunizationwww.gwhealthpolicy.org/immunizationStone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM et al. 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: Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med 2002; 136(9):641-651.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 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.time for prevention? Am J Public Health 2003; 93(4):635-641.