Healthcare Officials Push for Better Payment of Vaccinations

Cheryl Clark, for HealthLeaders Media , May 20, 2009

Ask William Schaffner, MD, why 50% of all adults don't get recommended vaccinations and he'll give you five reasons.

"Funding, funding, funding, funding, and if you haven't gotten it yet, funding," says the president-elect of the National Foundation for Infectious Diseases.

If governments want to get adults vaccinated to prevent billions of dollars in healthcare costs, not to mention avoid unnecessary death and disability, they need to incentivize physicians and hospitals—the entire healthcare delivery spectrum—to promote immunization, he says. That's just not being done today.

For any health reform package, it has to be an important consideration. That's why Schaffner's foundation has launching a "Call To Action" campaign and informational Web site promoting vaccines in an effort to bring adult immunization to the top of the priority list in the national health reform debate.

The Web site has detailed information from the Centers for Disease Control and Prevention on 11 approved vaccines, as well as estimates of how much not vaccinating people costs the healthcare system.

Schaffner says 90% of children get recommended vaccines because there is an adequate reimbursement and infrastructure in place (through providers and schools) that makes sure of it. Not so for adults. "The nation has not made the same sustained commitment to vaccination for adults as for children," says the foundation's Web site.

Take, for example, herpes zoster, or shingles, a painful reactivation of the chickenpox virus that affects half of people over age 60. And for one in five of those, a more severe, sometimes life-altering condition called post herpetic neuralgia sets in that can lead to congestive heart failure, heart attack, type II diabetes, and major depression.

The U.S. Food and Drug Administration approved an effective vaccine three years ago, yet only 3% or 4% of seniors over age 60 have received it, says the Vanderbilt University chairman of Preventive Medicine.

Although Medicare will pay for it, the vaccine was put under Part D, which means the patient must be told about the vaccine by a physician, purchase the vaccine from a pharmacist, and "brownbag" it back to his or her doctor to have it administered.

A bill was introduced in the last session of Congress to have reimbursement for herpes zoster vaccine moved to Part B, so the physician can be reimbursed for administering it. But, Schaffner says, "it didn't go anywhere."

One way around the barrier is to have pharmacists trained to administer the vaccine, which is the way it's done at Vanderbilt, Schaffner says. "But as you can see, that's a complete disincentive to have physicians interested in this program. My quip is that having a new shingles vaccine is like having a brand new Cadillac that you keep in the garage."

There needs to be a payment structure to allow busy pharmacists, who are in short supply throughout the country, to take time to do it as well.

Medicaid, the government's health plan for the poor, also is extremely inadequate in how it reimburses providers for vaccinations, in part because policies vary depending on the state, Schaffner says.

And there are 40 million people without health insurance for whom vaccination rates are spotty at best.

Third, even those who have health insurance may be in plans that don't cover vaccinations or have deductibles or co-pays that require that patient to pay out-of-pocket.

Additionally, the number and schedule of vaccines to be administered is confusing. So the Web site offers health providers a handy tool to help guide clinical practice.

Beverly Sha, MD, of Rush University Medical Center in Chicago, says reimbursement for vaccination is so poor and spotty, "It's a difficult thing for physicians. We never really know what we're being reimbursed because we're too busy worrying about our patients."

But when she decided to look into the cost of one vaccination for influenza, she found that the cost to buy the dose was $14, and the cost of administering it was $10 to $15. But the reimbursement from the insurance company was $10 for the vaccine and $6 for administration. And that didn't include the time to log in the patient's chart, to properly stock and refrigerate the vaccine, or the cost of the needle, syringe, and alcohol.

"We're actually losing money doing this," he says.

Reimbursement should be standardized across the country, she says, adding that it wouldn't be that hard because the costs are fairly standard no matter where a vaccine is given.

For example, influenza costs more than $10 billion a year yet rates of vaccination against influenza range between 37% and 42% for adults between 18 and 64, and only 69% for people age 65 and older.

In an article published in the May 20 issue of the Journal of the American Medical Association, CDC epidemiologist Andrew Kroger, MD, says 50,000 deaths a year—36,000 of them due to influenza—can be attributed to illnesses for which effective vaccines are recommended. Another 260,000 hospitalizations a year add up the bill.

Pneumococcal vaccinations are received by only 33% of the population between age 18 and 64 and 66% age 65 and over. A mere 10% of women between age 18 and 26 receive human papillomavirus vaccine.

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