Old Challenges, New Opportunities in Financing Adult Vaccines

1
Old Challenges, New Opportunities in Financing
Adult 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

2
Insurance Coverage of Adult Vaccines

• Insurance coverage for adults
• Scope of adults underinsurance for vaccines
• Definition Person has insurance coverage, but
  benefits do not include coverage for all
  recommended vaccines
• How many adults are potentially affected?
• Who is potentially affected?
• Opportunities to address the challenges
• Considering employers and insurers as
  constituents
• Options within consumer-driven health plans
• Increasing public demand for adult vaccines

3
What insurance coverage do adults have?
adults (millions) with private insurance with public insurance uninsured
Overall 217.3 69 26 17

Bureau of the Census, 2005
4
What insurance coverage do adults have?
adults (millions) with private insurance with public insurance uninsured
Overall 217.3 69 26 17
Age 18-44 years 45-64 years 65 years 110.6 71.5 35.2 67 76 61 12 14 95 24 14 1
Proportions sum to gt100 because of coverage by
more than one type of insurance in a given year.
uninsured reflects no coverage at any time in
2004.
Bureau of the Census, 2005
5
What insurance coverage do adults have?
adults (millions) with private insurance with public insurance uninsured
Overall 217.3 69 26 17
Age 18-44 years 45-64 years 65 years 110.6 71.5 35.2 67 76 61 12 14 95 24 14 1
Proportions sum to gt100 because of coverage by
more than one type of insurance in a given year.
uninsured reflects no coverage at any time in
2004.
Bureau of the Census, 2005
6
What insurance coverage do adults have?
adults (millions) with private insurance with public insurance uninsured
Overall 217.3 69 26 17
Age 18-44 years 45-64 years 65 years 110.6 71.5 35.2 67 76 61 12 14 95 24 14 1
Zoster vaccine
Proportions sum to gt100 because of coverage by
more than one type of insurance in a given year.
uninsured reflects no coverage at any time in
2004.
Bureau of the Census, 2005
7
What insurance coverage do adults have?
adults (millions) with private insurance with public insurance uninsured
Overall 217.3 69 26 17
Age 18-44 years 45-64 years 65 years 110.6 71.5 35.2 67 76 61 12 14 95 24 14 1
Proportions sum to gt100 because of coverage by
more than one type of insurance in a given year.
uninsured reflects no coverage at any time in
2004.
Bureau of the Census, 2005
8
What insurance coverage do adults have?
adults (millions) with private insurance with public insurance uninsured
Overall 217.3 69 26 17
Age 18-44 years 45-64 years 65 years 110.6 71.5 35.2 67 76 61 12 14 95 24 14 1
Flu vaccine
Proportions sum to gt100 because of coverage by
more than one type of insurance in a given year.
uninsured reflects no coverage at any time in
2004.
Bureau of the Census, 2005
9
What insurance coverage do adults have?
adults (millions) with private insurance with public insurance uninsured
Overall 217.3 69 26 17
Age 18-44 years 45-64 years 65 years 110.6 71.5 35.2 67 76 61 12 14 95 24 14 1
Proportions sum to gt100 because of coverage by
more than one type of insurance in a given year.
uninsured reflects no coverage at any time in
2004.
Bureau of the Census, 2005
10
What insurance coverage do adults have?
adults (millions) with private insurance with public insurance uninsured
Overall 217.3 69 26 17
Age 18-44 years 45-64 years 65 years 110.6 71.5 35.2 67 76 61 12 14 95 24 14 1
Tdap vaccine
Proportions sum to gt100 because of coverage by
more than one type of insurance in a given year.
uninsured reflects no coverage at any time in
2004.
Bureau of the Census, 2005
11
How many adults are potentially underinsured?

• Institute of Medicine Vaccine Financing in the
  21st Century (based on Wood, 2003)
• 33 of nonelderly adults
• Not specific to antigen
• No information regarding cost-sharing

12
How many adults are potentially underinsured?

• National study of underinsurance for vaccines
• Funded by National Immunization Program/NVPO
• Private and public employers
• 1618 plans
• Asked for information about all health plans they
  offered their employees
• Enrollment, premiums, deductibles
• Obtained information about 5 specific vaccines
  covered under such plans
• Influenza, PPV23, hepatitis B, varicella, MMR
• Obtained information about preventive care caps
• Limits on spending for prevention each year

13
Coverage of vaccines, by plan financing strategy
Plan-level data
Self-insured Fully insured
Influenza
Pneumococcal
Hepatitis B
Varicella
MMR
14
Coverage of vaccines, by plan financing strategy
Plan-level data
Self-insured Fully insured
Influenza 89 84
Pneumococcal 88 80
Hepatitis B 49 79
Varicella 39 77
MMR 40 83
Plt.05
15
How many adults are potentially underinsured?
Plan-level data
All 5 vaccines covered None of 5 vaccines covered P value
Plan financing Self-insured Fully insured
Mean plan deductible
Preventive care cap
16
How many adults are potentially underinsured?
Plan-level data
All 5 vaccines covered None of 5 vaccines covered P value
Plan financing Self-insured Fully insured 39 74 61 26 .05
Mean plan deductible 234 539 .09
Preventive care cap 12 45 .01
17
How many adults are potentially underinsured?
Plan-level data
All 5 vaccines covered None of 5 vaccines covered P value
Plan financing Self-insured Fully insured 39 74 61 26 .05
Mean plan deductible 234 539 .09
Preventive care cap 12 45 .01
18
How many adult enrollees are underinsured?

• For all 5 vaccines
• For influenza vaccine and PPV23

19
How many adult enrollees are underinsured?

• For all 5 vaccines
• 29 underinsured
• For influenza vaccine and PPV23
• 22 underinsured

20
How many adult enrollees are underinsured?

• For all 5 vaccines
• 29 underinsured ? 37 million adults 18-64
• For influenza vaccine and PPV23
• 22 underinsured ? 28 million adults 18-64

21
Who is underinsured for vaccines?
Underinsured for influenza and PPV23 Underinsured for all 5 vaccines Distribution of enrollees overall
Employer size lt100 100-499 500 33 11 56
Plan financing Self-insured Fully insured 62 38
22
Who is underinsured for vaccines?
Underinsured for influenza and PPV23 Underinsured for all 5 vaccines Distribution of enrollees overall
Employer size lt100 100-499 500 28 10 62 28 10 62 33 11 56
Plan financing Self-insured Fully insured 73 27 74 26 62 38
23
Who is underinsured for vaccines?
Underinsured for influenza and PPV23 Underinsured for all 5 vaccines Distribution of enrollees overall
Employer size lt100 100-499 500 28 10 62 28 10 62 33 11 56
Plan financing Self-insured Fully insured 73 27 74 26 62 38
24
Opportunities to Address Underinsurance

• In health plans
• By motivating public demand for vaccines

25
Employers and Insurers as a Constituency

• Current primary constituency for vaccine
  information health care providers
• ? information to patients
• ? information to employers and insurers

26
Employers and Insurers as a Constituency

• Current primary constituency for vaccine
  information health care providers
• ? information to patients
• ? information to employers and insurers
• Opportunity See employers insurers as a
  target constituency for vaccine information

27
Why Should Employers and Insurers Listen?

• Direct cost implications
• Health services utilization
• Pharmacy utilization

28
Why Should Employers and Insurers Listen?

• Direct cost implications
• Health services utilization
• Pharmacy utilization
• Indirect cost implications
• Absenteeism
• Presenteeism

29
Why Should Employers and Insurers Listen?

• Direct cost implications
• Health services utilization
• Pharmacy utilization
• Indirect cost implications
• Absenteeism
• Presenteeism
• Attraction / retention of employees

30
Why Should Employers and Insurers Listen?

• Direct cost implications
• Health services utilization
• Pharmacy utilization
• Indirect cost implications
• Absenteeism
• Presenteeism
• Attraction / retention of employees
• Is vaccination coverage a factor in employee
  decision-making about employment or health plans?

31
Recent Trend Consumer-Driven Health Plans

• High-deductible (1000) health plans
• Give people the chance to say no to
  themselves
• Health savings accounts (HSAs)
• Tax benefits in contributions and in withdrawals
• Increasing enrollment nationally
• Unclear implications for vaccinations

32
Promoting Prevention in Consumer-Driven Plans

• Exclude preventive services from the plan
  deductible
• Employer funding of HSAs

33
Promoting Prevention in Consumer-Driven Plans

• Exclude preventive services from the plan
  deductible
• But may have preventive care cap
• Employer funding of HSAs
• Can encourage use of preventive services
• But is not compulsory

34
Motivating Public Demand for Adult Vaccines

• How many adults want all recommended vaccines
  covered in their health plans?
• How might we induce public demand for recommended
  vaccines among adults?

35
Understanding Adults Demand for Vaccines

• Nationally representative study of adults
  regarding vaccination coverage in their private
  health plans for all recommended vaccines
• 995 adults aged 18-64 (potential employees)
• Web-based survey

Funded by National Science Foundation and Robert
Wood Johnson Foundation
36
Vaccine Coverage Study Hypothetical Scenario

• Respondent is employed
• Employer is only source of coverage
• Health plan options
• Basic coverage
• Td, influenza
• Comprehensive coverage
• Basic newly recommended vaccines

37
Vaccine Coverage Study Hypothetical Scenario

• Respondent is employed
• Employer is only source of coverage
• Health plan options
• Basic coverage
• Td, influenza
• Comprehensive coverage
• Basic newly recommended vaccines
• ? For 3 more per month in premium paid by
  employee

38
Understanding Adults Demand for Vaccines

• 79 of adults would opt for the comprehensive
  coverage plan
• Varied by experience with Medicaid
• Did not vary by sociodemographic factors

Davis and Fant, 2005
39
Understanding Adults Demand for Vaccines

• 79 of adults would opt for the comprehensive
  coverage plan
• Varied by experience with Medicaid
• Did not vary by sociodemographic factors
• Of those who would not opt for new vaccine
  coverage
• 48 would not pay for a new vaccine under any
  circumstances
• Influenced by attitudes about vaccine
  effectiveness and safety, and by income

Davis and Fant, 2005
40

• In summary . . .

41
Underinsurance Impact on Vaccinations

• Underinsurance likely affects 25 of nonelderly
  employed US adults
• May explain substantive proportion of
  undervaccinated nonelderly adults
• Majority of underinsured work for large employers
  and are enrolled in self-insured plans
• Opportunities to address underinsurance
• Communicate with employers and insurers as a
  constituency
• Support preventive care emphases in
  consumer-driven health plans
• Motivate demand among adults for whom vaccines
  are indicated

42
Underinsurance Challenges for the Future

• Pandemic influenza
• Zoster vaccine for adults 60 years old
• Vaccines for Adults legislation

43
Underinsurance Challenges for the Future

• Pandemic influenza
• Greater involvement of employers?
• Zoster vaccine for adults 60 years old
• Vaccines for Adults legislation

44
Underinsurance Challenges for the Future

• Pandemic influenza
• Greater involvement of employers?
• Zoster vaccine for adults 60 years old
• More direct communication with employers and
  insurers?
• Coordination with CMS (Medicare)?
• Vaccines for Adults legislation

45
Underinsurance Challenges for the Future

• Pandemic influenza
• Greater involvement of employers?
• Zoster vaccine for adults 60 years old
• More direct communication with employers and
  insurers?
• Coordination with CMS (Medicare)?
• Vaccines for Adults legislation
• Chances for passage in current fiscal climate?
• Would better plan coverage obviate need for
  underinsurance provisions?

46
(No Transcript)
47
Promoting Flu Vaccine for Elders viaDTC-style
Campaign Cost-Effectiveness