1. NVAC Vaccine Financing Stakeholders Activities Update: Assuring Vaccination of Children and Adolescents without Financial Barriers CDR Angela Shen National Vaccine Program Office February 3, 2010

2. Background April 2008 Vaccine Financing Stakeholder Meeting Representatives from six sectors provided views on vaccine financing NVAC used information to inform recommendations September 2008 Recommendations Approved February 2009 Cost estimates Presented* September 2009Implementation Plan Update December 2009Pediatrics Supplement

3. Background- Stakeholder Sectors 1. Consumers 2. Vaccine Distributors and Purchasers 3. Manufacturers 4. Federal, State and Local Government Health Departments 5. Employers, Payers and Health Insurers 6. Health Care Providers (HCP) & Organizations

4. Structure of Recommendations Block 1 VFC and the underinsured Block 2 Vaccine administration reimbursement Block 3 Business practices in private provider offices Block 4 Health insurance plans Block 5 Activities of federal agencies Block 6 Activities of state agencies and offices Block 7 Adolescent vaccination in complementary venues

5. Block 1 VFC and the Underinsured

6. Recommendation #1: Vaccines for Children program (VFC) should be extended to include access to VFC eligible underinsured children and adolescents receiving immunizations in public health department clinics Directed to: Federal Government- Congress *Stakeholders monitoring health care reform legislation (HCRL) Manufacturers: Support this recommendation though emphasize opposition to use of public sector vaccine for private sector use Consumers: Continue to seek opportunities to work toward achieving expansion of VFC Contacted appropriate legislators and sign letters of support Language included in House version of health reform legislation authorizing expansion

7. Block 2 (Rec. 2-5) Vaccine administration reimbursement

8. Recommendation #2: VFC should be expanded to cover vaccine administration reimbursement for all VFC-eligible children and adolescents. Directed to: Federal Government- Congress Stakeholders Reached out to CMS to actively support Monitoring health care reform legislation

9. Recommendation #3: CDC & CMS should annually update, publish, and disseminate actual Medicaid vaccine administration reimbursement rates by state Directed to: Federal Government- CDC, CMS Federal Government: CMS post online - Table of 2008 Medicaid administration reimbursement rates are currently available on CMS website. Manufacturers: Support publications which provide transparency and promote consistency in vaccine administration reimbursement

10. Recommendation #4: CMS should update the maximum allowable Medicaid administration reimbursement amounts for each state and include all appropriate non-vaccine related costs as determined by current studies Directed to: Federal Government- CMS Consumers: Support this recommendation Manufacturers: Reached out to CMS to encourage action

11. Recommendation #5: Increase the federal match (i.e. a larger federal proportion) for vaccine administration reimbursement in Medicaid to levels for other services of public health importance Directed to: Federal Government- Congress ASH has been made aware

12. Block 3 (rec. 6-9) Business practices in private provider offices

13. Recommendation #6: AMA's RVS Update Committee (RUC) should review its RVU coding to ensure that it accurately reflects the non-vaccine costs of vaccination including the potential costs and savings from the use of combination vaccines. Directed to: Health Care Provider & Organizations HCP & Organizations: AAP’s Pediatric multiple antigen coding proposal: 2009 RUC approved two new IZ administration CPT codes that will become effective in CPT 2011. Allows for discrete reporting for each vaccine component antigen (e.g. DTaP=3 antigens) – Manufacturers support CMS’ RUC accepted recommendations; considering and valuation in the 2011 RBRVS

14. Recommendation #7: Vaccine manufacturers and third-party vaccine distributors should work with providers on an individual basis to reduce the financial burden for initial and ongoing vaccine inventories, particularly for new vaccines. Directed to: Vaccine Manufacturers, Vaccine Distributors and Purchasers Manufacturers implementing provider programs including:  Requiring payment for vaccines only after administration  Flexible payment plans (30, 60, 90 days) with varying levels of discounts (e.g. 2 percent)  Volume discounts  90+ day payment terms extended during launch new vaccines

15. Rec. #7: Reduce provider financial burden (cont.) Manufacturers:  Return programs for nearly expired vaccine  Sales team work with office to manage inventory  Staff vaccine reimbursement support center  Coupon and dose replacement programs – providers inadvertently administer vaccine to patient without coverage

16. Recommendation #8: Professional medical organizations should provide their members with technical assistance on efficient business practices associated with providing immunizations Directed to: Health Care Providers & Organizations HCP & Organizations: Developed and updated “Business Case for Pricing Vaccines and Vaccine Administration” shared with members and payers. Notifies members and carriers of new CPT codes. Developed a free on line module “Immunization: Best Business Practices” targeting practices to assist with lowering their costs of immunizing and increasing quality of immunization services. Allowed on line access to 2009 Pediatrics Supplement, free of charge. Manufacturers: Actively support efforts of medical societies including AMA, AAP, and AAFP Provide assistance to providers through call center, on line CPT coding seminars, and sales calls (e.g. coding, fair and complete reimbursement) Works with providers to enhance service delivery (e.g. registry, reminder/recall)

17. Rec. #8: Efficient business practices (cont.) Consumers: Hosted meetings with state AAP chapter, sessions included billing and coding Encouraged other states to conduct similar activities, will disseminate information to partners nationwide Payers: Provide provider assistance for best business practices

18. Recommendation #9: Medical providers, particularly in smaller practices, should participate in pools of vaccine purchasers to obtain volume ordering discounts. Directed to: Health Care Providers & Organizations HCP & Organizations: Some AAP chapters are pursing group purchasing agreements AAP provides a list of group purchasing organizations online in their Practice Management section and actively promotes as part of best practice AAP- A list of group purchasing organizations is also available on Practice Management online and actively promoted to members as a best practice Consumers: Hosted stakeholder meetings Manufactures: One- charges uniform price to all providers, thereby eliminating bias towards larger practices

19. Block 4 (Rec. 10-13) Health insurance plans

20. Recommendation #10: Professional medical organizations, and other relevant stakeholders should develop and support additional employer health education efforts. Directed to: Federal Government; Employers, Payers & Health Insurers; Health Care Providers & Organizations HCP & Organizations: Educate public and private payers on pediatric services through op-ed articles, letters to the editor, and other news related articles. E.g. AAP “Promoting the Value of Pediatrics” Support HC employers efforts in supporting IZ E.g. IAC Manufacturers: Created and support provider education programs, vaccination programs, and workplace immunization initiatives Provide funding for philanthropic advocacy programs (e.g. grass roots)

21. Recommendation #10: Professional medical organizations, and other relevant stakeholders should develop and support additional employer health education efforts. Directed to: Federal Government; Employers, Payers & Health Insurers; Health Care Providers & Organizations Employers, Payers and Health Insurers: Developed and disseminated guidance for members  E.g. webinars, electronic messaging, NBGH materials education materials addressing larger issue adequate preventive service coverage Working to establish employer based vax programs and provider education (emphasis on adult IZ) Conducted primary research to understand large employer vaccine coverage.  E.g. - NBGH knows that 98% of its large employer members cover childhood vaccines at 100%.

22. Recommendation #11: Health insurers and all private healthcare purchasers should adopt contract benefit language that is flexible enough to permit coverage and reimbursement for new or recently altered ACIP recommendations as well as vaccine price changes that occur in the middle of a contract period. Directed to: Federal Government; Employers, Payers & Health Insurers; Health Care Providers & Organizations HCP & Organizations: Developed model contract language including vaccine contract addendum as a guide for appropriate coverage and payment for immunizations. Educational materials are available online (e.g. AAP checklist, AAP PediaLink module online modules for contract negotiations

23. Rec. #11: Flexible contract language (cont.) Employers, Payers and Health Insurers: Developed a resource guide for employers outlining value of adolescent vaccination, created messaging around flexible contracts – Model contracts can raise antitrust issues and are inconsistent with general contracting rights of private parties Manufacturers Have not heard about providers having problems reimbursements with regard to price increases; Manufacturers give advance notice

24. Recommendation #12: All public and private health insurance plans should voluntarily provide first-dollar coverage (i.e., no deductibles or co- pays) for all ACIP-recommended vaccines and their administration for children and adolescents. Directed to: Employers, Payers, & Health Insurers *Many believe this may be resolved under HCRL HCP & Organizations AAP Endorses “Principles on Benefit Plan Coverage and Payment”  Preventive care must be covered as a first dollar benefit and appropriately paid  Pediatricians must receive adequate and separate payment for vaccines and their administrations to cover the total direct and indirect expenses.

25. Rec. #12: First dollar coverage (cont.) Employers, Payers and Health Insurers: Developed resource guide for employers and continually recommends all employers cover all recommended preventive services NVPO: Contracting with NORC to characterize the implications including cost estimates

26. Recommendation #13: Insurers and healthcare purchasers should develop reimbursement policies for vaccinations that are based on methodologically sound cost studies of efficient practices. Directed to: Employers, Payers, & Health Insurers HCP & Organizations: AAP “Business Case for Pricing Vaccine and Immunization Administration” outlines the costs associated with vaccines and immunizations.  This information is shared with payers.  June 2009- AAP sent letter to payers encouraging review of payer policies Employers, Payers and Health Insurers: Supports methodologically rigorous research and cost studies on efficient practices.

27. Block 5 (Rec. 14-17) Activities of federal agencies

28. Recommendation #14: Congress should request an annual report on the 317 Program Directed to: Federal Government- DHHS & Congress Federal, State, Local: CDC has responded to annual requests for 317 Report Report is used for educational efforts by public health agencies Manufacturers: Actively support 317 Coalition through advocacy and financial support Consumers: Participates in the 317 Coalition’s annual effort to build Congressional support for 317 funding and specifically provides suggested report language to Congress annually that includes a request for this report

29. Recommendation #15: CDC and CMS should continue to collect and publish data on the costs and reimbursements associated with public and private vaccine administration according to NVAC standards for vaccinating children and adolescents. Directed to: Federal Government- CDC & CMS HCP & Organizations: AAP’s Private Payer Advocacy Advisory Committee has encouraged private insurance carriers to use CDC’s Private Sector Cost as a source for pricing vaccines. NVPO: Conducting a study to examine payment and reimbursement practices of providers

30. Recommendation #16: NVPO should calculate the marginal increase in insurance premiums if insurance plans were to provide coverage for all routinely ACIP-recommended vaccines Directed to: Federal Government- NVPO NVPO tasked ASPE to develop a policy brief: ASPE presented preliminary data from a report entitled “2009 Premiums for Routine Immunizations” at June 2009 NVAC meeting.

31. Recommendation #17: NVAC should convene one or more expert panels representing all impacted stakeholders to consider whether tax credits could be a tool to reduce or eliminate underinsurance. Directed to: Federal Government- NVAC Monitoring health care reform legislation

32. Block 5 (Rec. 18-21) Activities of federal agencies

33. Recommendation #18: CDC should substantially decrease the time from creation to official publication of ACIP recommendations Directed to: Federal Government- CDC CDC: Provisional ACIP recommendations are posted online following a Committee vote, and are thus available prior to official publication. MMWR publication slots are being scheduled in anticipation of ACIP recommendations. Manufacturers: Some expressed concern that progress has not been made in reducing the time from ACIP vote to publication

34. Recommendation #19: Congress should expand Section 317 funding to support the additional national, state and local public health infrastructure needed for adolescent & childhood vaccination programs Directed to: Federal Government- DHHS & Congress Federal, State & Local: Actively work to secure funding at requested level Advocated for funding through ARRA  ASTHO, AIM and CDC collaborate to ensure appropriate expenditure of funds Consumers: Actively supports the 317 Coalition’s efforts for expanded funding and legislative efforts to expand funding Helped secure $300 M in ARRA funding

35. Rec. #19: Expand 317 (cont.) Manufacturers: Support lobbying efforts through 317 Coalition for increased funding and expanded service delivery sites Have concerns about how funds are spent including if all $300 million in stimulus funding will be spent

36. Recommendation #20: Continue federal funding for cost-benefit studies of vaccinations targeted for children and adolescents. Directed to: Federal Government Sectors supporting costing studies, though some are concerned about diverting funds from other core programs Manufacturers: Funded costing studies including those related to adults Welcome the opportunity to cooperate with initiatives

37. Recommendation #21: State, local and federal governments along with professional organizations should conduct outreach to physicians and non- physician providers who currently serve VFC-eligible children and adolescents to encourage these providers to participate in VFC. Directed to: Federal, State & Local Health Departments; Health Care Providers Federal, State & Local: Used H1N1 vaccination program to outreach to new providers HCP & Organizations: Provide information about VFC enrollment online VFC enrollment promoted through online provider modules Consumers: Support broader professional participation in immunization and promotes VFC Publishes periodical “Vaccinate Women”  Targeting OB GYN’s to encourage vaccination Developed Immunization Handbook

38. Rec. #21: Participation in VFC (cont.) Employers, Payers and Health Insurers: Disseminated guidance, but not successful citing costs to participate [Current VFC provider enrollee rates are low compared to number of potential enrollees, provider state cost and administrative burden as barriers] Manufacturers: Work with OBGYN’s and pharmacists to increase alternative vaccination venues Work with “Vaccine for Teens” program with NBA to reach teens Commissioned a RAND study re: increasing teen vaccination Work with state health departments and organizations (e.g. AAP, AAFP) to promote increased coverage Sponsors reminder/recall programs

39. Block 6 (Rec. 22) Activities of state agencies and offices

40. Recommendation #22: States and localities should develop mechanisms for billing insured children and adolescents served in the public sector. Directed to: State and Local Governments- State & Local Health Departments Federal, State & Local: Pilot grants to develop plans to bill were provided through ARRA ASTHO will publish a “how to” guide for state & local health departments ASTHO will work with CDC to develop & disseminate lessons learned from H1N1 billing Consumers: AIM hosted a presentation at their annual meeting last week highlighting this success in Oregon and supporting other states efforts to do this

41. Rec. #22: Billing insured children (cont.) Manufacturers: Offer software tools to public and private sector providers to help determine the status of a patients insurance coverage Encourage research to identify current barriers and disincentives for not billing insured children in the public health setting Employers, Payers and Health Insurers: Disseminates guidance to VFC providers during office visit about best billing practices Bill private insurance first, then Medicaid and CHIP as payers of last resort

42. Block 7 (Rec. 23-24) Adolescent vaccination in complementary venues

43. Recommendation #23: Ensure adequate funding to cover all costs (including those incurred by schools) arising from assuring compliance with child and adolescent immunization requirements for school attendance. Manufacturers: Successfully opposed state bills that would grant widespread exemptions to immunization as a pre-requisite to day care and school attendance

44. Recommendation #24: Promote shared public and private sector approaches to help fund school-based and other complementary-venue child and adolescent immunization efforts.**ARRA funding support Federal, State & Local: ASTHO disseminated best practices from successful H1N1 school based vaccination efforts (ME, RI, AR) ASTHO promoted state regulation changes during H1N1 (e.g. allowing additional medical professionals to vaccinate) Consumers: Supported “No Child Left Behind” provision in House HCRL – supporting demonstration programs to test feasibility of using elementary and secondary schools as influenza vaccination centers Published information online:  School based vaccination programs  Promotional materials for vaccination strategies

45. Rec. #24: School based immunization efforts Manufacturers: Supported studies by independent researchers Supported pilot school based immunization programs (state, local and county level) Work with drug stores and clinics to vaccinate

46. Respondent Recommendations A follow up Immunization Congress should be hosted by AMA/AAP to further explore partnerships to implement recommendations NVAC should prioritize recommendations (top 3-4) for implementation Stakeholders should use specific NVAC recommendations as leverage to make a case for resources and greater action on existing and potentially new programs

47. Respondent cited challenges to implementation Proposed state legislation from “anti-vaccine” groups Uncertainty of Health Care Reform Legislation  NVAC recommendations should be reviewed after Health Care Reform Legislation is in place

48. Stakeholder respondents 1. Consumers  Every Child by Two (ECBT)  Immunization Action Coalition (IAC)  317 Coalition 2. Vaccine Distributors and Purchasers  HIDA 3. Manufacturers  GlaxoSmithKline  MedImmune  Merck  Novartis  Pfizer  sanofi pasteur 4. Federal, State and Local Government Health Departments  ASTHO 5. Employers, Payers and Health Insurers Virginia Department of Medical Assistance Services (DMAS) National Business Group on Health (NBGH) America’s Health Insurance Plans (AHIP) 6. Health Care Providers (HCP) & Organizations American Academy of Pediatrics (AAP)

49. Many thanks 1-Amy Pisani 2-Lance Rodewald 3-Lance Gordon 4-Anna Deblois-Buchannan 5-Alan Rosenberg Natalie Matthews 6-Jon Almquist NVPO – Jovonni Spinner Sector Leads