Patients, physicians forgo adult vaccines over cost and coverage concerns

Many adults forgo recommended vaccines because of cost, according to a new study, either because they couldn’t afford a vaccine or because their clinician thought a vaccine would not be covered by the patient’s insurance plan and therefore did not recommend it.

The study, “Primary care physicians’ perspective on financial issues and adult immunization in the Era of the Affordable Care Act,” published in January 2017 in Vaccine, sought to identify the barriers to adult vaccination by surveying general and family practitioners shortly after the Affordable Care Act was implemented. Clinicians were asked about how many of their adult patients deferred or refused vaccines because of cost, as well as how often physicians did not recommend vaccine due to poor reimbursement practices. The research team also assessed how familiar clinicians were with Medicare coverage of vaccines and the vaccine-specific provisions within the ACA.

Among physicians who routinely recommended adult vaccines, 24% of general and 30% of family physicians reported patients deferred or refused vaccines for financial reasons in most cases. Of those physicians who did not recommend vaccines to their patients, 35% did so because they thought their patient’s insurance would not cover it and 38% because they thought the patient could be vaccinated more affordably somewhere else.

In terms of reimbursement, physician dissatisfaction was the highest when it came to Medicaid and Medicare Part B. Additionally, the study reported that anywhere from 36% to 71% of physicians were unaware of how Medicare covered certain vaccines, with the range dependent on the vaccine in question. Thirty-seven percent of physicians were completely unaware and 19% admitted to knowing “a little” about the ACA provisions affecting adult vaccination when the survey was conducted in 2013-three years after the reform was signed into law.

The study notes that most vaccine-preventable deaths occur in adults, yet vaccination rates in this age group remain low despite. Stakeholder have called for increased education among physicians and more resources to address the financial barriers surrounding adult vaccination.

Next: The ACA's impact on vaccines

The ACA’s impact on vaccines

While potential changes to the American healthcare landscape leave the future in question, under the ACA, non-grandfathered private health insurance plans were mandated to cover vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) without copays when administered by in-network providers. The ACA did not address, however, payments to providers for vaccine purchase and administration, according to the report.

The ACA also temporarily increased Medicaid reimbursements for vaccine administration, but did not mandate that state agencies participate and as a result, several states did not cover all of the ACIP-recommended vaccines.

“Overall, the ACA has improved access for adult patients to receive vaccines by expanding health insurance coverage for millions of Americans and by mandating several private insurance plans to cover ACIP recommended vaccinations,” said Laura P. Hurley, MD, a primary care physician at Denver Health and lead author of the study. “However, even with these vaccine-specific provisions of the ACA, gaps remain in the financial infrastructure of adult vaccines in terms of prohibitive costs for patients and perceived insufficient reimbursement for physicians, particularly from public payers.”

Financing adult vaccination is still complicated, Hurley said, particularly when it comes to patients with Medicare Part D. And it’s not just patients who have a difficult time understanding their benefits-it’s clinicians, too.

“Clinicians should have an understanding of which adult vaccines are covered by Medicare Part B versus Medicare Part D to best direct patients where they should receive vaccines,” she said.

Medicare.gov offers resources on coverage levels under the various Medicare options.

Some public health departments also have resources, in the form of 317 funds, that can be used to vaccine uninsured or underinsured adults, Hurley said, so clinicians can refer patients to their local health departments as one option. Vaccine manufacturers may also offer assistance programs that can defer the cost of adult vaccines.

Hurley said she hopes her research brings light and new solutions to the problematic financing of adult vaccines. One option, she says, could be to create a program similar to the Vaccine for Children program, a federally funded program that provides vaccine coverage to children who might not otherwise be vaccinated due to inability to pay. The program claims to have prevented 322 million illnesses since it was founded in 1994.

 “I would welcome discussions of an equivalent program for adults,” Hurley said.