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NVAC work group looks for solutions to vaccine financing
A substantial problem exists with vaccine financing in both the public and private sectors.
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WASHINGTON — The National Vaccine Advisory Committee’s Vaccine Financing Working Group proposed a new set of options for the committee to consider as solutions to address vaccine financing problems.
“What providers need to know is that NVAC is taking financing very seriously,” Walter A. Orenstein, MD, of the Emory Vaccine Center and member of the Infectious Diseases in Children editorial board, said in an interview. “NVAC recognizes that there is a financing problem and will make recommendations that will hopefully solve these problems. However, the stakeholders on the workgroup, including representatives of private providers, government, manufacturers and distributors, insurers, employers, consumers and others have very different takes on a number of the vaccine financing issues, and we realize that developing a set of recommendations may be very difficult. But the NVAC will forge ahead, and if a consensus of the workgroup cannot be reached, the NVAC itself will make recommendations by majority vote.”
Orenstein acknowledged the substantial problem with vaccine financing in both the public and private sectors and presented a draft of 27 options for recommendations to be considered for the group’s white paper at the recent NVAC meeting.
“Right now, there are a variety of stakeholder groups that are being represented, and thus far, we have not been able to reach a consensus on some of the most fundamental issues,” Orenstein said.
Public sector issues
According to Orenstein, the greatest problem appears to be in public sector financing. This includes purchase of vaccines for children who have traditionally relied on the public sector, particularly underinsured children served at public health clinics. In addition, it includes public sector payments to private providers for administration of publicly purchased vaccines for children. Through the Vaccines for Children (VFC) program, the public sector purchases vaccines for children on Medicaid, children without insurance and children who are American Indians/Alaska Natives. Only Medicaid offers an administration fee for these children and the levels of Medicaid fees vary substantially from state to state with some reimbursements less than $3 per dose administered.
One of the working group’s recommendations suggests that the Vaccines For Children (VFC) Program expand to include purchase of vaccines for underinsured children and adolescents who are served in public health clinics. Another option includes purchase of vaccines for the undersured no matter where they are served. This latter recommendation coincides with the Adolescent Working Group’s recommendation to “refine the VFC program so that all enrolled providers can use VFC vaccines to vaccinate adolescents who are underinsured for one or more of the recommended vaccines and those who cannot otherwise afford to be vaccinated.” However, there is substantial opposition among some stakeholders to covering the underinsured in any setting because it could erode the private sector market and serve as a disincentive for insurers to cover immunization in the future.
Another option Orenstein presented for the committee to consider was the recommendation to increase federal Section 317 funding to support vaccine purchase for all children and adolescents who traditionally rely on Section 317 for funding. Funds for 317, which are appropriated annually, have not kept up with recent additions of vaccines to the child and adolescent immunization schedule. This option would cover those vaccines.
An alternative would be for states to make up the gaps with their own funds. But trying to solve the financing crisis on a state-by-state basis is problematic. Many states have tight budgets and may not give priority to increasing their budgets to purchase vaccines. This could result in inequalities with some states covering underinsured children and some not. The latter could serve as reservoirs for transmitting vaccine-preventable infectious agents to other states. Thus, national solutions are preferred.
In terms of covering the cost of vaccine administration, the working group is considering an option to expand VFC funding to cover not only vaccines but reimbursement for vaccine administration of all eligible children and adolescents, including children on Medicaid and the uninsured.
“As we evaluate and consider these recommendations, I urge the committee to think about the potential they may have to make things better but also the potential they may have to make things worse,” Anne Schuchat, MD, assistant surgeon general of the United States Public Health Service, said during the meeting. “Many of us feel that the underinsured already have a program that addresses them, so let’s not make things worse.”
The working group further suggested that state, local and federal governments as well as professional organizations reach out to medical providers that are currently serving VFC–eligible children and adolescents to encourage providers to participate in VFC.
“Overall, there are many options to be considered, and many of the options are conflicting,” Orenstein said. “For example, if we open up the VFC to cover the underinsured for vaccine purchase, then there is no need to increase 317 funding. So this is what NVAC will have to work on for the next several months and figure out which options are the ones the committee will recommend and see if there are other options to consider.”
Private sector issues
Options to be considered under the private sector consist of the development and support of additional employer health education efforts (by the CDC, professional medical organizations and other relevant stakeholders) to communicate the value of preventive care as well as appropriate vaccinations. The hope is that if employers understood the individual and societal benefits of immunization, they would cover vaccination in all policies, thus eliminating the problem of underinsurance (ie, children with insurance whose policy does not cover a given vaccine).
Furthermore, the group is considering a recommendation for health insurers and private payers of health care coverage to adopt contract benefit language flexible enough to allow coverage and reimbursement for all new recommendations of the Advisory Committee on Immunization Practices as well as vaccine price changes that may occur in the middle of a contract period.
The NVAC Financing Working Group is also considering a recommendation that would urge employers and insurers to cover the full costs of immunization on a voluntary basis, exempted from any requirements for deductibles or co-pays (ie, first-dollar coverage). This option is somewhat different from the Adolescent Working Group’s recommendation that calls for mandates for all public and private health insurance plans to offer first-dollar coverage of all costs associated with the attainment, handling, storage and administration of all vaccines recommended by the ACIP for routine and catch-up use among adolescents.
“The ultimate goal of the Financing Working Group is to have a final set of options for recommendations for the NVAC to vote on in September. Where there are conflicting options, NVAC members will have to vote to determine which ones will appear as recommendations in the final report,” Orenstein said. “The committee will provide their input on these options to the working group, which will then modify the current options and present the final set of options to the NVAC at the September meeting. The NVAC will then determine which recommendations it supports.” – by Jennifer Southall
For more information:
- Orenstein W. NVAC Vaccine Financing workgroup white paper. Presented at: the NVAC meeting; June 3-4, 2008; Washington, D.C.