Insurance Coverage of Vaccines

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Insurance Coverage of Vaccines
Divisions of General Pediatrics and General
Internal Medicine, Gerald R. Ford School of
Public Policy, University of Michigan

• Matthew M. Davis, MD, MAPP
• Assistant Professor
• Pediatrics and Communicable Diseases,
• Internal Medicine, and Public Policy
• Child Health Evaluation and Research (CHEAR)
  Unit,
• University of Michigan

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Challenges for Insurance Coverage of Vaccines

• Scope
• Who and how many children are potentially
  affected?
• Why insurance coverage ? vaccine coverage
• Public programs
• Private insurance plans
• Opportunities to address the challenges
• What more do we need to know?

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When Insurance and Vaccines Werent Linked
Polio vaccination drive in a school gym, Kansas,
1950s (courtesy of Bentley Historical Library)
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When Insurance and Vaccines Werent Linked
Single vaccine efforts Infancy of private health
insurance plans Little or no public insurance
coverage
Polio vaccination drive in a school gym, Kansas,
1950s (courtesy of Bentley Historical Library)
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To Linking Insurance and Vaccine Receipt
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To Linking Insurance and Vaccine Receipt
Multiple vaccines Employer-sponsored plans as
dominant source of health insurance for
children National public insurance programs for
children (Medicaid and SCHIP)
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What insurance coverage do children have?
Kaiser Family Foundation, 2004
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Public-Sector Vaccine Financing

• Federal funds
• Vaccines for Children Program
• Covers vaccine purchase for
• Uninsured
• Medicaid
• Native American / Alaska Native
• Underinsured, in federally qualified or rural
  health centers
• Section 317
• Vaccine purchase and system infrastructure
• State funds
• Vaccine purchase and system infrastructure

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Challenges to Public Insurance and Vaccines

• Patient access to Medicaid/VFC providers
• Worse with states frozen and/or decreasing
  reimbursement to providers
• Funding for public-sector vaccine purchase in
  face of rising vaccine costs
• Increasing numbers of vaccines
• Comparatively higher costs of newer vaccines
• Timing of new recommendations vis-à-vis
  government budget cycles

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Underinsurance in Private Health Plans

• Definition Child has insurance coverage, but
  benefits do not include coverage for all
  recommended vaccines
• Estimated to affect gt10 of child enrollees in
  private plans (Institute of Medicine, 2004)
• Approximately 5 million children
• Known to promote fragmentation of care (Davis
  et al, Pediatrics 2003)

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Etiologies of Underinsurance in Private Plans

• Trends in benefits and plan design
• Regulatory factors
• Employers benefit decision-making
• Role of employees (proxies for children)

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Trends in Therapeutic versus Preventive Benefits

• Traditional emphasis on coverage of therapeutic
  benefits
• Role of managed care
• Initially higher likelihood of coverage for
  preventive services
• With managed care backlash ? return to plans with
  fewer restrictions and more emphasis on
  catastrophic coverage
• Failure to control rises in health care costs
• Implementation of preventive care caps that limit
  coverage for vaccines

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New Trend Consumer-Driven Health Plans

• High-deductible (1000) health plans
• Give people the chance to say no to
  themselves
• Health savings accounts (HSAs)
• Increasing enrollment
• Unclear implications for vaccinations

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Regulatory Factors

• Legislative mandates for childrens vaccines
• VFC provision for underinsured children

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Limits of State Vaccine Coverage Mandates

• Self-insured health plans
• Employer (typically gt500 employees) bears
  financial risk
• gt50 of US employees enrolled in such plans
• Number of children enrolled not known
• Catastrophic gt preventive coverage
• Employee Retirement Income Security Act (ERISA,
  1974)
• Federal statute
• Self-insured plans exempt from state insurance
  mandates

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Provisions for the Underinsured under VFC

• VFC
• Must receive vaccines at rural or federally
  qualified health centers
• Fragmentation of care
• Challenging to verify underinsurance
• State-specific extensions of VFC
• Depend on private provider participation
• Challenging to verify underinsurance
• Employer awareness of VFC provisions
• Employers not encouraged to cover more recent
  vaccines if employees dont complain about
  fragmented care

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Benefit Decisions of Self-Insuring Employers

• Inadequate information about short-term return on
  investment for newly recommended vaccines
• Costs more evident than benefits
• New vaccine recommendations contrast with other
  benefit considerations that are more expensive
• Vaccines may be crowded off employers agenda
• Essential to benefits design employees
  preferences
• What are employees demands about childrens
  vaccines?

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Addressing Challenges Insurance and Vaccines

• Parents demand for childhood vaccine coverage
• Employers buy-in for newly recommended
  vaccines
• Effects of current trends in health plan benefit
  design

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Parents Demand for Childhood Vaccines

• Carrots
• Information campaigns about the benefits of new
  vaccines, targeting parents
• Will parents communicate demands for broader
  coverage in private plans to employers and
  insurers?
• If coverage not available, will parents seek
  public-sector vaccines or pay out-of-pocket?
• Sticks
• Daycare and school entry requirements
• Could requirements be implemented more broadly
  and more rapidly after new recommendations?
• Potentially hindered by vaccine shortages

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Employers Buy-in for Childhood Vaccines

• Acknowledge and target employers economic
  interests
• What are empiric data about productivity and
  absenteeism related to childhood vaccine
  coverage?
• What are employers incentives to design benefit
  plans that prioritize prevention for children?
• Communicate with employers as a unique and
  influential constituency
• Distinct from parents and providers
• Influenced by consultants
• Can the case be made for the importance and
  urgency of coverage for newly recommended
  vaccines?

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Effects of Current Health Plan Design Trends

• Consumer-directed health plans
• What are immunization rates for children enrolled
  in high-deductible health plans?
• Do parents with high-deductible plans seek
  public-sector vaccines rather than pay out of
  pocket, or forgo newer vaccines altogether?
• What are opportunities to encourage preventive
  care utilization in high-deductible plans?
• Preventive care caps
• Within a family, whose preventive care gets
  priority the parent who needs a mammogram or
  the adolescent who is eligible for newly
  recommended vaccines (meningococcal conjugate,
  Tdap, HPV)?

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Conclusions

• Insurance coverage likely an influential factor
  in undervaccination for US children
• Uninsured and publicly insured limited access
  to care and to VFC providers in context of
  constrained public funds
• Privately underinsured benefit coverage not in
  step with latest recommendations
• Opportunities to address underinsurance
• Parents employees
• Employers decision-making
• Effects of plan benefits and payment designs

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Employees Preferences for Vaccine Coverage

• National sample of adults (potential employees)
• Offered hypothetical scenario of plans that
  differed only in vaccine coverage
• 3 more per month to assure coverage of any newly
  recommended vaccine(s) in the next year

Davis and Fant, 2005
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Employees Preferences for Vaccine Coverage

• National sample of adults (potential employees)
• Offered hypothetical scenario of plans that
  differed only in vaccine coverage
• 3 more per month to assure coverage of any newly
  recommended vaccine(s) in the next year
• 79 of parents with children in household said
  they were willing to bear higher premiums to
  assure coverage of new vaccines

Davis and Fant, 2005
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Employees Preferences for Vaccine Coverage

• National sample of adults (potential employees)
• Offered hypothetical scenario of plans that
  differed only in vaccine coverage
• 3 more per month to assure coverage of any newly
  recommended vaccine(s) in the next year
• 79 of parents with children in household said
  they were willing to bear higher premiums to
  assure coverage of new vaccines
• Are such plans feasible?
• Will employees indicate they want coverage like
  this?

Davis and Fant, 2005