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Will the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 provide physicians with adequate remuneration for vaccine administration?
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Providers are understandably concerned about reimbursement rates under Medicaid. However, there are opportunities for change in this area.
As part of health reform, CMS is required to create and oversee a new Center for Medicare and Medicaid Innovation (CMI) by Jan. 1. Ten billion dollars has been allocated from 2011 to 2019 and $5 million for the design, implementation and evaluation of models.
The HHS secretary has been granted broad authority to implement the CMI through regulation, policies, guidance and grant-making without the possibility for either administrative or judicial review. After consultation with states, federal agencies, and clinical and analytical experts in medicine and health care management, CMI will test innovative service delivery and payment models that have the potential to reduce costs while preserving or enhancing health care quality for Medicare and Medicaid enrollees and dual eligibles, according to language included in the health care reform bill.
The HHS secretary will select from 20 models identified in the law, including new provider payment methodologies. The secretary will be required to evaluate how each model affects the quality of care and spending under Medicare and Medicaid. If the secretary and the chief actuary of CMS determine that the model fails to achieve quality improvement and reduction of spending, the model may be terminated or modified.
Based upon the results of the evaluations, the secretary may expand the models nationwide, without regard to existing administrative requirements.
Alexandra Stewart, JD, director of the Epidemiology of U.S. Immunization Law Project at George Washington University’s Department of Health Policy
Although the health care reform law appears to open immunization access to many more young and old Americans, it fails to adequately address the implementation side of the equation of how private sector physicians will be compensated to maintain and administer expanded government-sourced free vaccines such as those provided by the Vaccines for Children (VFC) program. Private practitioners administer about 80% of all vaccines given in the United States and, the VFC program provides nearly 50% of the vaccine purchased in this country, so it remains a big issue that is going to get bigger.
Expansion of the VFC program to include underinsured children who lacked immunization benefits and were excluded from receiving free vaccine in their medical homes will go a long way to improving access to immunizations.
The state-based vaccine administration fee benchmarks established by the Health Care Financing Administration (HCFA) 16 years ago have not been adjusted since inception, and only seven states have met their funding obligations to compensate private sector immunization providers adequately for giving immunizations. The AAP would like the health care reform law to build vaccine maintenance and administration compensation into the VFC program as a federal benchmark so that pediatricians would receive consistent remuneration similar to what Medicare pays for adult immunization services rendered currently.
The AAP also wants to develop a compensation system that recognizes the importance of combination vaccines and create a formula that would favor the use of combination products. Right now, there is a financial disincentive to use combination vaccines.
Thomas Saari, MD, professor of pediatrics emeritus, division of pediatric infectious disease, University of Wisconsin School of Medicine and Public Health.