Although the barriers to children and adults receiving vaccines differ, experts agree that new strategies are desperately needed to address the lack of compliance with national immunization guidelines. Simply recommending that a group get immunized is clearly not getting the job done.
A recent report on the status of adult immunization in the United States estimated that low immunization rates result in as many as 40,000-50,000 deaths annually due to diseases that could be prevented by vaccines.
“Thousands of lives could be saved each year if we could increase the number of adults who receive routine and recommended vaccinations,” said Jeffrey Levi, Ph.D., executive director of Trust for America's Health, which contributed to the report.
“To achieve that goal, we need a national strategy to make vaccines a regular part of medical care and to educate Americans about the effectiveness and safety and efficacy of vaccines,” he added.
The most striking findings: A third of adults aged 65 years and older in 36 states were not immunized against pneumonia, despite recommendations from the Centers for Disease Control and Prevention (CDC) that this age group receive the pneumococcal vaccine. In Oregon, the state with the highest immunization rate, 27% of seniors had not received this vaccine. The lowest rate in the country was Washington, D.C., where 47% of seniors had not received it.
In 2007, just 36% of all adults were vaccinated against seasonal flu. In 2008, only 69% of people aged 65 years and older got the influenza vaccine, according to the report, which was based on 2006-2008 data and was funded by a grant from the Robert Wood Johnson Foundation and released in conjunction with the Infectious Diseases Society of America (IDSA) and Trust for America's Health.
Annually, “approximately 36,000 Americans die of the seasonal flu, 5,000 die from pneumonia, and more than 1 million adults get shingles,” according to the report said. Those types of preventable diseases cost an estimated $10 billion every year.
The lack of a national immunization strategy for adults, such as the one in place for children, is one of the main reasons for the low immunization rates, in addition to the lack of insurance coverage, Dr. William Schaffner, chair of IDSA's Immunization Work Group and co-author of the report, said during a telebriefing unveiling the report.
In addition, the health care system is not set up to deliver preventive services and many adults don't have regular checkups. Many physicians who care for adults are not accustomed to providing vaccines in their offices, a factor that contributes to the misunderstanding and misinformation about vaccine safety and effectiveness on the part of both clinicians and patients.
Although primary care physicians are more likely to provide vaccines than other adult health care providers, many adults only receive medical care from specialists, noted Dr. Schaffner, professor and chair of preventive medicine, Vanderbilt University, Nashville.
Barriers to Pediatric Immunization
For children, a key barrier to immunization is the fact that some private insurers are taking too long to agree to cover vaccines once they've been recommended by the CDC's Advisory Committee on Immunization Practices (ACIP), said Dr. Jon R. Almquist, who coauthored an article about reducing financial barriers to vaccination. The article appeared in a special supplement to Pediatrics focusing on vaccine issues (Pediatrics 2009;124:S451-4).
“We've got documentation that physicians very commonly hold back [on giving a particular vaccine] because they don't know whether private industry is covering that vaccine yet,” said Dr. Almquist, who is a member of the National Vaccine Advisory Committee.
“And when the physician gives the patient a vaccine and the insurance company rejects [coverage for] it or pays for a similar vaccine that costs significantly less, those things make a huge problem for the physician,” he continued.
Dr. Almquist explained that once ACIP recommends a vaccine, some time elapses—occasionally 6 months or sometimes more—until the announcement of the recommendation is printed in the Morbidity & Mortality Weekly Report. Part of that delay is to give the CDC time to negotiate contracts with manufacturers of the new vaccine.
But once announced in the MMWR, the vaccine is covered under the federal Vaccines for Children (VFC) program and available for states to obtain for their VFC-eligible patients. It is at this point that private insurers usually begin to act.
“The insurance industry has had variable responses” to the MMWR publication, he continued. For example, some insurers automatically cover whatever vaccines ACIP recommends, while others send the recommendation to an internal review board for approval, which can delay things further.
Delayed coverage by private insurers is problematic because the VFC program always covers new vaccines right away. “The providers have said, ‘It's really a problem having children in the Vaccines for Children program getting the vaccine [from us] when we can't give it to privately insured patients; we're treating people differently and that sets us up for a lawsuit,’” said Dr. Almquist, who recently retired from private practice.
Recent data from America's Health Insurance Plans, an industry trade group, showed that the average time that elapses between a vaccine's announcement in the MMWR and private insurers beginning to cover the vaccine has dropped from 3 months to 1 month, “which is really good,” Dr. Almquist added. And although insurers did not want to see vaccine coverage mandated by federal or state government, they did agree to make first-dollar reimbursement for ACIP-recommended vaccines a “voluntary standard” for the industry, he said.
Another problem for physicians is the variance in reimbursement rates for vaccines. Three studies included in the supplement showed large variations in what insurers reimbursed physicians for a particular vaccine. “Sometimes they paid less than the cost of the vaccine itself, and sometimes they paid twice as much as what the vaccine cost,” said Dr. Almquist, who is also chair of a subcommittee on immunization at the American Academy of Pediatrics. One study in the supplement by Dr. Gary Freed and his colleagues at the University of Michigan, Ann Arbor, found that the maximum and minimum reimbursements for a single vaccine differed from $8 to more than $80 (Pediatrics 2009;124:S459-65).
But physicians also shouldered some of the blame because some of them paid very high prices to purchase the vaccines in the first place, Dr. Almquist noted. The study by Dr. Freed and his colleagues found that “there was a considerable difference between the maximum and minimum prices paid by practices, ranging from $4 to more than $30” for specific vaccines.
“What we found is that physicians are pretty lousy business people,” said Dr. Almquist. “Sometimes they were paying more than what the spot price was if they just went to the Internet and paid dose by dose.” In their article, Dr. Almquist and his colleagues recommend that physicians use purchasing groups to buy vaccines, and that they negotiate with insurers for better payment rates for both vaccines and administration of vaccines.
The reimbursement rate for vaccine administration needs include the costs involved in administering vaccines—things like counseling, documentation, and labor, Dr. Almquist said. In one study, Judith E. Glazner of the Colorado School of Public Health, Aurora, and her colleagues found that the total variable cost per vaccination averaged $11.51; for two vaccinations, more than one-third of health plans paid physicians less than the combined variable cost of $23.02. The authors noted that “more than one third of the [insurer] payment agreements paid the practices less than the combined variable costs for two immunizations” (Pediatrics 2009;124:S492-8).
Given the problems physicians have being adequately paid for the administration of vaccines, the federal government should pay the entire cost of vaccine administration under the VFC program, rather than leaving some of the cost to be paid by the states, according to Dr. Almquist and his colleagues. “Some states pay a significant amount, and others contribute almost nothing,” he said.
Although paying the entire administration fee would cost the federal government “a big chunk of change”—an estimated $800 million, with savings to states of $300 million—it would be well worth the investment, he added. “Everybody agrees that immunization is one of the most cost-effective things we can do for the health of this nation.”
Solutions for Adult Populations
For adults, Dr. Schaffner recommended that all clinicians become familiar with the adult immunization schedule, establish a plan to review immunizations patients need, and determine how to order, stock, and keep track of vaccines in the office.
Litjen Tan, Ph.D., director of medicine and public health for the American Medical Association, said that all health care providers should provide full coverage for all the adult vaccines recommended by ACIP, and that a vaccine program for uninsured adults should be created.
“We should make reviewing [adult] patients' immunization histories a standard part of care and vaccines should be offered in appropriate medical encounters,” when people are already going to see the doctor, when it is convenient for both parties, such as annual physicals, prenatal visits, and cancer screening visits, he added.
Other recommendations for improving adult vaccination rates include requiring coverage of all vaccines under Medicare Part B, increasing public education about the effectiveness and safety of vaccines, and increasing the research, development and production of vaccines, which would include surveillance and research on safety.
Elizabeth Mechcatie contributed to this story.
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