Women In Government's Policy Roundtable on Utilization of Adult Immunizations Texas Department of State Health Services Dr. John Hellerstedt, Commissioner Janna Zumbrun, Associate Commissioner April 2017

Presentation Overview Adult Immunizations Recommendations and Funding Adult Vaccination Coverage Rates in Texas Texas Uninsured Adults Adult Safety Net DSHS Adult Immunization Initiative

Adult Immunizations Each year, the CDC’s Advisory Committee on Immunization Practices (ACIP) approves immunization schedules recommended for persons living in the United States. The adult immunization schedule provides a summary of ACIP recommendations on the use of licensed vaccines routinely recommended for adults aged 19 years or older. These recommendations guide the availability of vaccines within the Texas Adult Safety Net and any other publically supported routine adult immunization activities in Texas.

Helping Adult Clients Pay for Vaccines We know that paying for adult vaccines can be a barrier to vaccination. Both the health care provider and patient should be aware of the vaccines that are covered under various insurance plans – this is a shared responsibility. Here are a few options that we do know about: Under the Adult Safety Net, vaccines are available with no cost-sharing or co-payments when vaccines when the patient indicates they cannot pay. Otherwise, they may be asked to pay up to $25 per dose for the admin fee. Adult Medicaid (ages 19 through 64 years) – all ACIP-recommended vaccines This is for All vaccines routinely recommended on the CDC Adult Immunization Schedule, including Td/Tdap, HPV, Hep A, Hep B, Var, MMR, Zoster and PPSV23 and PCV13 are covered. Providers must use private stock vaccine and bill Medicaid for the cost of the vaccine and the vaccine administration fee Recently, coverage was extended to include all ACIP-recommended vaccines given in pharmacy settings, too. Medicare Part B---Allows for an annual flu vaccine, as well as pneumococcal vaccine and hepatitis B vaccine for persons in certain high risk groups If they have Medicare Part D it may cover additional vaccines like Zoster, MMR or Tdap however, Coverage varies by Part D plan—check with the insurance company for details Example: Blue Cross Blue Shield (BCBS)’s policy which began April 1, 2015 now covers HPV4, HPV9, MMR and Tdap vaccines at pharmacies for adolescents and adults per ACIP recommendations. Adult Safety Net – (age 19+) covers most ACIP-recommended vaccines with no co-payments or cost-sharing Adult Medicaid (ages 19 through 64 years) – all ACIP- recommended vaccines Coverage extended to all ACIP-recommended vaccines given in pharmacies to individuals 19 years and older Adult Medicare (beginning at age 65 years) Part B – annual flu, pcv13, ppsv23, and hepatitis B (for high- risk) Part D – Zoster, MMR, Tdap; coverage varies by plan CHIP covers pregnant adult women (Tdap only) Private Insurance Out of Pocket Payments Example of update in coverage policy Blue Cross Blue Shield covers HPV, MMR, Tdap in pharmacies

Uninsured Adults 18-64 Years of Age Adults receive immunization through a variety of means. The Adult Safety Net covers only uninsured adults. Texas continues to have one of the highest uninsured adult populations in the country. Uninsured Adults 18-64 Years of Age in Texas HSR Population Uninsured % Uninsured 1 497,865 125,559 25.2% 2/3 4,803,752 1,167,520 24.3% 4/5N 840,797 220,156 26.2% 6/5S 4,354,478 1,134,982 26.1% 8 1,668,138 389,506 23.3% 7 1,997,730 426,138 21.3% 9/10 865,993 251,264 29.0% 11 1,247,546 486,259 39.0% Texas 16,276,299 4,201,384 25.8% *Source: 2014 Small Area Health Insurance Estimates Program, US Census Bureau

​​Adult Immunization Coverage Levels 2015 Texas BRFSS This provides a brief overview of available coverage rates for adults in Texas. As shown here, the flu coverage for older adults is much higher than it is for the general adult population. Our highest coverage rates are for MMR and the rates for Pneumonia vaccine coverage is much higher with older adults than the general adult population. Medicare has had a number of special initiatives through CMS QIOs (quality improvement Organizations) over the past few years that focused on older adults and has likely contributed to the higher coverage rates in that population. ​Vaccine ​Coverage Level (%) ​Adult Flu: All Ages ​38.3 ​Adult Flu: 65+ 66.2 ​​Tetanus, diphtheria, and pertussis (Tdap) ​21.2 ​Pneumococcal 34.7 ​Pneumococcal: 65+ ​70.9 ​Measles, Mumps, Rubella (MMR) 59.1 ​HPV: 1 or more doses ​13.3

Adult Safety Net (ASN) Overview The Adult Safety Net (ASN) Program supplies publicly-purchased vaccine at no cost to enrolled providers.  The aim is to increase access to vaccination services in Texas for uninsured adults. Funding for 2014, 2015 and 2016 is from State General Revenue and Federal discretionary funds. Currently available in DSHS Regional Clinics, Local Health Departments, FQCH/RHCs, STD/HIV Clinics, and other enrolled providers.

Adult Safety Net (ASN) Overview Continue to serve only uninsured adults, 19 years of age and older Vaccines currently available include Hepatitis A, Hepatitis B, Combination Hepatitis A/B, MMR, HPV 9, Pneumococcal 13 and 23, Tetanus, Diphtheria, and Pertussis (Td and Tdap), Meningococcal Conjugate (MCV4), and Zoster

ASN Providers By Type (As of April, 2016) Texas ASN Providers in 2016 Source: DSHS Re-enrollment data 2016 Most of the ASN providers are within FQHCs and Public Health Departments. ASN Providers By Type  (As of April, 2016) FQHC/RHC 231 Public Health Department 222 Community Health Center 33 STD/HIV 12 Other 18 Total 516

ASN Doses Administered in 2015 Source: DSHS ITEAMS Reporting Web Janna, this has all the doses on one slide. COH is City of Houston- directly federally funded. SAM is San Antonio Metro – directly federally funded. This shows that about 33% of the total doses administered are Tdap or Td. The next most frequently used vaccine is HepB, followed by MMR. HEP A Hep A/B HEP B HPV MCV4 MMR PCV13 PPSV23 Td Tdap Var Total 8,015 8,568 21,936 12,024 10,910 17,240 8,870 8,713 4,061 44,950 5,928 151,215 % 5.30% 5.67% 14.51% 7.95% 7.21% 11.40% 5.87% 5.76% 2.69% 29.73% 3.92% 100.00%

Adult Immunization Initiative Adult Immunizers in 2017 and 2018 We will be working with 950 adult immunizers (pharmacies, community health centers and large provider networks) over the next 2 years to implement the adult immunization standards in their practices. The adult standards focus on the following: ASSESS immunization status of all your patients at every clinical encounter. Stay informed. Get the latest CDC recommendations for immunization of adults. Implement protocols and policies. Ensure that patients' vaccine needs are routinely reviewed and patients get reminders about vaccines they need. Strongly RECOMMEND vaccines that patients need. Share tailored reasons why vaccination is right for the patient. Highlight positive experiences with vaccination. Address patient questions and concerns. Remind patients that vaccines protect them and their loved ones against a number of common and serious diseases. Explain the potential costs of getting sick. ADMINISTER needed vaccines or REFER your patients to a vaccination provider. Offer the vaccines you stock. Refer patients to providers in the area that offer vaccines that you don't stock. DOCUMENT vaccines received by your patients. Participate in your state's immunization registry (ImmTrac). Help your office, your patients, and your patients' other providers know which vaccines your patients have had. Follow up. Confirm that patients received recommended vaccines that you referred them to get from other immunization providers. Adult Standards: 1. Assess 2. Recommend 3. Administer or 4. Refer 5. Document

Associate Commissioner, Disease Control & Prevention Thank you Janna Zumbrun, Associate Commissioner, Disease Control & Prevention Janna.Zumbrun@dshs.texas.gov