Medicare Needs to Encourage Broader Coverage of Vaccines

Despite various attempts to increase the vaccination rate amongst adults, Medicare beneficiaries are still susceptible to extensive cost-sharing for recommended vaccines, according to a study by Avalere.

Many factors contribute to low adult vaccination rates, including limited public awareness about adult vaccinations, lack of vaccination requirements for adults, gaps in recommending vaccines during health care visits, and complex insurance coverage for adult vaccines. As such, rates of vaccine-preventable illnesses are high among older adults and while most private insurance must cover the vaccines, few Medicare consumers have equivalent coverage, Caroline Pearson, senior vice president of Avalere, said in a statement.

There have been several efforts to expand the vaccination rate among US adults such as the development of Healthy People 2020 by the Office of Disease Prevention and Health Promotion, the issuing of 17 recommendations on vaccine-preventable conditions for providers by the CDC, the Affordable Care Act mandating most commercial health plans provide full coverage for vaccinations, and the encouragement of Part D plans (PDPs) to utilize vaccine tiers by Medicare. Vaccine tiers are intended to offer low cost-sharing amounts as each tier has an associated copay; they generally influence enrollee and prescriber choices.

Avalere examined coverage trends for 10 vaccines between 2011 and 2016 in order to determine how effective the aforementioned efforts were for Medicare beneficiaries. The researchers selected 10 vaccines that either had age-specific recommendations for seniors or were for conditions that seniors were especially predisposed to as suggested by the Advisory Committee on Immunization Practices. These vaccines included Boostrix, Zostavax, Varivax, Menomune, Havrix, VAQTA, Energix-B, RECOMBIVAX-HB, Twinrix, and Tenivac.

The researchers discovered that as of 2016, 12% of Medicare enrollees had limited access to vaccines without having to pay out of pocket, and no stand-alone PDPs provided complete coverage. Medicare Advantage (MA)-PDs primarily used copays while PDPs tended towards coinsurance, where 80%-90% of MA-PDs had fixed dollar copays and 47%-72% of stand-alone PDPs had fixed dollar copays.

In its first year as an option (2012), only 2.1% of MA-PDs included any of the 10 drugs; 2015 saw 2.9%-3.2% of MA-PDs using the vaccine tier. When covered, the vaccines were usually on the preferred brand drug tier. Few PDPs used the vaccine tier. Prior to 2012, 0.3%-1% of MA-PDs covered the drugs with no cost sharing and in 2015 9.2% of MA-PDs did. Overall, vaccination coverage has increased but the majority of Medicare beneficiaries continue to share costs for immunizations.

Avalere concluded that since PDPs do not have the same financial incentives, policy makers may want to reconsider existing Part D policies and requirements in order to achieve the Healthy People 2020 goals.