Emerging Gaps in Financing for New Vaccines Tracy Lieu, MD, MPH for Grace Lee, MD, MPH Center for Child Health Care Studies, Dept of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School

Plan Background Vaccine implementation by states and cities Barriers to implementation Strategies for financing In Phase 2, which was the national survey, we sent written surveys and conducted 1 hour semi-structured phone interviews with those who were not previously interviewed. This took place from Jan to Jun 2006. Surveys and interviews included questions about the…. Interviews were audiotaped, transcribed, and coded

Number of Vaccines in the Routine Childhood & Adolescent Schedule 1985 1995 2006 Measles Rubella Mumps Diphtheria Tetanus Pertussis Polio Measles Rubella Mumps Diphtheria Tetanus Pertussis Polio Hib HepB Varicella Measles Rubella Mumps Diphtheria Tetanus Pertussis Polio Hib HepB Varicella Pneumococcal disease Influenza Meningococcal disease HepA Rotavirus HPV* 7 10 16 * Provisional ACIP recommendation, not yet published

Federal Contract Prices for Vaccines Routinely Recommended for Children and Adolescents  $1,200 $900 $155 $45

VFC and Section 317 Vaccine Funding to Immunization Programs

State and City Immunization Programs Types of funding: VFC 317 State—variable (0% to ~45%) Policies for implementation depend on available funding

Childhood Vaccine Doses by Funding Source, 2005 Source: Vaccine manufacturers Biologic Surveillance Data 2005 Note: Does not include influenza vaccine

State Vaccine Supply Policies 1994 - 2000 VFC-eligible Under-insured Insured Universal All VFC enhanced None VFC only None* * Unless 317 or state funds available

State Vaccine Supply Policies 2000 – present (post-pneumo) VFC-eligible Under-insured Insured Universal All Universal select Some VFC enhanced None VFC enhanced select VFC only

Study of Implementation and Financing of New Vaccines Aims Describe states’ current policies for new vaccines Identify barriers to implementation Describe strategies to address gaps in financing

Contributors AIM CDC MA Immunization Program Claire Hannan CDC Jeanne Santoli Lance Rodewald Mark Messonnier MA Immunization Program Susan Lett Immunization Program Managers Harvard Grace Lee Tracy Lieu Jim Sabin Donna Rusinak Charlene Gay

Methods State & city immunization program managers Qualitative phase 1-hour interviews with 9 states, Nov – Dec 2005 National survey Written surveys and 1-hour interviews with all program managers, Jan – Jun 2006

Topics Overall vaccine supply policy Status of implementation of newest vaccines Barriers to implementation Strategies to address gaps in financing

Results Participation Experience in position 49 of 53 program managers Response rate 89% Experience in position Median 5 years Range 6 months – 27 years

Vaccine Supply Policy - 2006

Changes in Vaccine Policy Universal 2 states Universal Select VFC enhanced 1 state 5 states VFC enhanced select 3 states VFC only

Implementation in VFC-eligible Children in 49 states/cities

Implementation in Underinsured Children in 49 states/cities

Where Underinsured Children May Seek Vaccination Federally-qualified health centers or rural health centers (not enough) Private providers Public clinics

Underinsured Children Not Covered via Private Providers

Underinsured Children Not Covered in Public Clinics

Barriers to Vaccine Implementation Funding Supply Other issues

Funding Gaps as a Barrier to Implementation in the Underinsured 317 State * Among states not implementing in all underinsured

Supply Issues as a Barrier to Implementation in the Underinsured * Among states not implementing in all underinsured

Other Reasons for Delay Low demand for hepatitis A Need to use up existing doses of Td Equity Delay until funding secured for entire population

Other Reasons for Delay Federal allocation and need to build up supply Lack of published recommendations Need to modify registry

Strategies to Address Limitations in Financing Since funding was the major barrier for programs in delivering vaccine to underinsured, we asked program managers about strategies they used to address limitations in vaccine financing

Strategies to Expand Vaccine Funding Strategy # of states Annual state appropriation 25 One-time state appropriation 18 Expanded designations of FQHCs / RHCs 14 SCHIP 11

Strategies to Expand Vaccine Funding Strategy # of states Annual health plan appropriation 4 One-time health plan appropriation 3 Other sources: Title 20, tobacco funds, MCH block grants, Medicaid match, Title V

Expanded Designations of FQHCs or RHCs (14 states) All private and public VFC providers (1) All public VFC providers (3) Some public VFC providers (9) Some public VFC providers through state funding (1)

Other Strategies # of states Strategy Prioritized subgroups (e.g., Menactra) 31 Used state/federal funds to offset each other 28 Limited provider vaccine choice 27

Other Strategies, cont. Strategy # of states Asked providers to pay for loss of vaccine 19 Negotiated state contract with manufacturer 11 Decreased adult vaccine purchase 9 (of 32) Billed insurance companies for patients vaccinated at public clinics

Conclusions Underinsured children face growing gaps in vaccine financing Many states have had to change overall supply policies

Conclusions Expansion of access for underinsured children is needed Immunization program managers have developed a variety of strategies for funding

to immunization program managers! Thank You to immunization program managers!

State Policies State health insurance mandate Provider vaccine choice Yes-ACIP/AAP recs 35% Yes-no requirement 17% No 48% Provider vaccine choice Yes-all vaccines 54% Yes-some vaccines 20% No 26%

Number of Vaccines in the Routine Childhood & Adolescent Schedule