A Payer Perspective on Pharmacy-Based Immunization Services and Insurance Coverage

AJMC^®:

What are your impressions of the broadly low uptake of routinely recommended immunizations for preventable diseases in the United States? Why is this important to health plans and other payers?

Schaecher: A number of factors play into the low vaccination rate in the US. First and perhaps foremost is the “antivaccination” movement that continues to gain traction. Despite the low or no cost of vaccinations, due to misinformation that feeds into the bias of some individuals (particularly middle- to high-income individuals), they are actively choosing to not vaccinate their children against some diseases as they have the unfounded perception that the health risk of the vaccinations exceeds the benefit. This stems in part from the lack of significant populations of children in recent years experiencing the diseases and subsequently a lack of front-of-mind perception about the consequences of the diseases they are intended to prevent.

A second factor is healthcare disparity for social and economic reasons; vaccinations, though low or no cost for folks with insurance, are not available to those without insurance. Thus, poor and disadvantaged populations do not have access or easy access to vaccinations, which reduces uptake. This same population may also be misinformed about vaccines and thus shun them due to ignorance and fear.

Another factor is vaccination burden, particularly in children. The number of recommended vaccinations for children can be staggering, and families will choose to space them out further, not because they are not in favor of them, but [instead] due to the logistics of getting them and the associated costs.

Lastly, the lack of effectiveness of the flu vaccine has resulted in a certain halo effect of folks not getting other vaccines as they question the need, if they still “got the flu” despite getting the vaccination.

As to why this is important to health plans is simply that vaccinations tend to prevent downstream healthcare costs, as they prevent disease manifestations; though, in some circumstances, such as rotavirus vaccination, vaccines are not cost effective.

AJMC^®:

What is the payer’s role in addressing/increasing vaccination rates?

Schaecher:The payer’s role is being part of a team to promote vaccinations and to reduce the barriers to access. This is most often done by reducing member cost for the vaccinations. [Payers] also can assist in member reminders and education.

Where administration of a vaccine is cost effective, the payer should reduce member cost share to promote vaccination.

AJMC^®:

What has been the impact of community pharmacy in expanding/improving immunization rates?

Schaecher:Expanding access to community pharmacies has helped improve vaccination rates, as it makes vaccination more convenient for patients.

AJMC^®:

How does benefit design affect access to immunizations, and can you address the challenges and opportunities associated with single and joint benefits?

Schaecher: Reducing member cost is 1 of the tools that can help improve vaccination rates by reducing 1 of the barriers to access.

Joint benefit was established to improve access for members. The implications to moving something to joint benefit is it opens the potential number of providers who will perform the vaccinations, which should improve vaccination rates; pharmacy-only or medical-only benefits have the potential to misalign access due to self-funded plans, particularly [those that] carve out pharmacy from medical benefit and they are adjudicated by different plans. Joint benefit allows broadest community access.

AJMC^®:

In your experience, how would you describe awareness at the community pharmacy level regarding the possibility of vaccine coverage as a pharmacy-only benefit?

Schaecher:Pharmacies are more vigorous in promoting allowed vaccinations than provider offices; they recognize the financial benefits of getting patients to vaccinate through them.

AJMC^®:

As you weigh the current challenges and opportunities of immunizations, how will payers continue to shape the vaccine spectrum in the US over the next several years?

Schaecher: As payers define levels of payment for vaccines, that will determine uptake and access. At the end of the day, the single most important factor which I believe shapes whether vaccines are taken up by patients is member cost share. The greatest challenge will be to overcome member bias against vaccine through education and to find ways to engage providers in actively promote vaccines to our members.

AJMC^®:

Based on current trends, what is the future of pharmacy-based immunization?

Schaecher:I think it will continue to expand as it is recognized that community pharmacies increase vaccination rates, help to maintain herd immunity, and promote the public’s health. I see the number of vaccinations being allowed in nonclinical community settings increasing through community/payer alignments and cooperation.

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