1. Vaccine Delivery, Financing, and Demand Subgroup

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

3. Question 1 Are the current private/public programs for adult immunization adequate?

4. Answer 1 HP 2010 Targets Age < 65 in target group Age > 64

5. Question 2 What changes should be made to enhance acceptance and promote demand for influenza vaccine by the public and health officials?

6. 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

7. 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

8. Answer 2 “Priorities should shift from documenting disparities to assessing interventions strategies …..that separate the contribution of the patient, provider, and institution “Unequal Treatment” “Unequal Treatment” Institute of Medicine 2002

9. Questions 3 What changes could be made to strengthen this programmatic infrastructure?

10. 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”

11. Critical Issues What is financing? Who finances vaccination? What is the effect of financing on delivery? Are there other ways to increase delivery?

12. What Is Financing? Raising revenue to pay for a good or service Module 1: Health Sector Reform and Sustainable Financing World Bank

13. Who Finances Vaccination? Manufacturers and distributors Patients –Out of pocket expenses –Opportunity cost Providers –Overhead and communication –Screening and assessment –Vaccine and administration EmployersInsurer –Reimbursement –Overhead and communication

14. Who Finances Vaccination? Patient Costs Component Time (min) Cost Opportunity cost Time in office* Time in office*15-20 $3 - $4 † Time before/after Time before/after ‡15-20 $6 - $8 Out-of-pocket costs Vaccine and administration ¶ $0 - $20 Travel costs** $1 - $7 Total patient cost 30-40$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

15. ComponentTime(min)Cost (2003 $) Observed labor † 5-11 $1 - $8 Unobserved labor & costs Unobserved labor & costs ‡ 38 38 $12 - $33 Vaccine-- $7 - $9 Total provider cost 43-49 $20 - $50 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)

16. Who Finances Vaccination I: 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) VaccinationEmployerSponsored*Medicare Covered80-84% 95% † Reimbursed57% 83% ‡

17. Component Non- Medicare Medicare Paid by insurer $12.34 $ 4.81 Co-pay, deductible 1.50 1.50 2.90 † 2.90 † Coordination of benefit 0.17 0.17 2.03 2.03 Total$14.01$9.74 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

18. 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 Who Finances Vaccination? III. Medicaid Coverage and Reimbursement* * Source: Rosenbaum S

19. Who Finances Vaccination? Summary Insurance (reimbursement) NonePartialFull* Patient*$35$20$15 Provider (cost) † mass clinic ($20) mass clinic ($20)$0$9$6 appointment ($50) appointment ($50)$20$29$26 Insurer$0 $6‡ $14** Total ---------$35 - $55--------- * $15 time/travel costs; patient pays $20 (no insurance) $5 (copay), $0 (full) † Adapted from Coleman ‡ Medicare ** Private insurer

20. What is the Effect of Financing on Delivery? Decreasing Time It Takes to Get Vaccinated HP 2010 Target Percent Vaccinated When Vaccinated Source: Fishbein

21. What is the Effect of Financing on Delivery? Small Co-payments Percent Vaccinated When Vaccinated HP 2010 Target Source: Fishbein NVPO grant

22. 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)

23. 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

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

25. V F A Vaccines for Adults +

26. 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 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 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 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.

27. McGlynn, E. A. et al. N Engl J Med 2003;348:2635-2645 Adherence to Quality Indicators, According to Mode

28. 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