Vaccine Systems - Arizona Department Of Health Services

Vaccine Systems

Where Vaccines Come from VFC Kids – public fundsPrivately Insured kidsPrivate Purchase fromvaccine manufacturersCMSCDCState HealthLocal Health andPrivate ProvidersBabies are born everyday,none arrive immunized –Dr Daniel Cloud

VFC Program Vaccines for Children Program was created in 1993 VFC is an entitlement program for all ACIPrecommended Vaccines Eligible children through age 18 are: Medicaid/AHCCCS enrolledUninsured (no insurance at all)Native AmericanUnderinsured only in acommunity health center

Additional Public Funds for Vaccine317 Vaccine FundingA program that evolved over time from poliovaccination assistance and mass immunizationcampaigns to support direct delivery ofimmunization services to health departmentsfor families that could not afford vaccines.

Past 317 Funding Use Underinsured ChildrenInsured children at public clinicsOutbreak controlAdult programsArizona used 317 funds to cover insured childrenat public clinics and birth dose of Hep B. Used to fill the gaps

Changes: Current 317 funding 317 funding is needed for local healthdepartment operations Recruiting providersImplementation and oversight of VFCInformation systemsAssessment of coverage levelsPreventing Misuse of federal

Changes to Federal Funding No federally funded vaccine to privatelyinsured kids even at the health department Including insured patients with a high deductable VFC vaccine for underinsured kids at acommunity health center or deputized clinicafter June 2013.

State/Local Funding used to fill the gaps Arizona lost 10 million in state funding Lowest per capita spending on Public Health State statute – must provide all schoolrequired vaccines at no cost to parent Forced to develop billing for privately insuredvaccine Legislation passed requiring payment

Arizona’s Vaccines for Children (VFC) Programas of October 1, UninsuredchildrenUnderinsuredchildrenInsured childrenPublic Providers –non- FQHCs(ie: County HealthDepartments, IHS,Phx Fire, Schoolprograms)Private ProvidersFQHCs andDeputizedFQHCsPrivate healthinsurancePrivate healthinsuranceKidsCare

Arizona’s Vaccines for Children (VFC) ProgramMedicaideligiblechildrenNative AmericanchildrenUnderinsuredchildrenPublic Providers –non- FQHCs(ie: County HealthDepartments, IHS,Phx Fire, Schoolprograms)Private ProvidersFQHCs andDeputizedFQHCsHighDeductibleinsuredFully InsuredchildrenDeputizedFundedthroughpayments frominsuredpatients orcash paymentOut ofPocketOut of PocketPrivate healthinsuranceOut of PocketPrivate healthinsurancePrivate healthinsuranceUninsuredchildren

State Vaccine Financing Systems 4 types VFC only – Private providers receive vaccines for federal VFC eligiblechildren only VFC & Underinsured – Private providers receive vaccines forunderinsured children also. State Immunization Program uses state/localfunding to provide all ACIP recommended vaccines.

State Vaccine Financing Systems Universal Select – all children, regardless of insurance status,receive all ACIP recommended vaccines for free, except for a few vaccines.State Immunization Program uses state/local funding to provide all ACIPrecommended vaccines. Universal - all children, regardless of insurance status, receive allACIP recommended vaccines for free. State Immunization Program usesstate/local or health plan funding to provide all ACIP recommendedvaccines.

Anatomy of vaccine funding for children Public Insurance– Federal Vaccines for Children’s (VFC) funds– Federal 317 vaccine funds– SCHIP vaccine funds (KidsCare in Arizona) Private Insurance State Vaccine funds (variable from state to state)

Arizona Immunization Programis VFC Only

State Vaccine Financing Systems( As of 2002)VFC OnlyVFC & UnderinsuredUniversal lawareDistrict souriOhioOregonPennsylvaniaTennesseeVirginiaWest ucky MarylandMichiganMinnesotaMontanaNebraskaNew YorkOklahomaSouth CarolinaTexasUtahWyomingConnecticutNevadaNorth CarolinaNorth DakotaSouth DakotaVermontAlaskaIdahoMaineMassachusettsNew HampshireNew MexicoRhode IslandWashington

(2014 estimation)State Vaccine Financing SystemsVFC OnlyVFC & UnderinsuredSelectUniversal lawareDistrict of uriOhioOregonPennsylvaniaTennesseeVirginiaWest VirginiaWisconsinOklahomaSouth aNorth CarolinaNorth innesotaNew uth DakotaAlaska (0-35 months)New HampshireNew MexicoRhode IslandVermontWashingtonWyoming

State Vaccine Financing SystemsWashington- plan funded universal purchase system

State Vaccine Financing Systems Maine quarterly payments by covered lives Vermont pilot project PCPs required toparticipate assessment on front end byquarter New Hampshire- does not include selfinsured funds and must use any state orfederal funds first then asses each plan theremainder Mass- bill did not pass establishing a fund tocover select vaccines Conn- end of year assessment based on selfreport from plans- self insured not included New Mexico system- funded onreimbursement model using registry

Potential Problems Arizona has never been universal soassessments would require a fee Barriers to using public pricing contracts High rate of self insured plans

Vaccine Congress I, II and III Set of recommendations toimprove rates Bill for the Counties Increase reimbursementrates Train Providers on BusinessPracticeRecommendations sent toNVAC

Payments Admin fee – Nurse time and supplies––––VFC rate set in 1983 at 15.43Medicaid “Bump” 22.33Average admin fee for AHCCCS Plans is 10.00Private sector range between 15- 25 Vaccine cost – Vaccine storage and handling– Each vaccine has a code, price set by plan– Range is 60% below purchase price to 30% aboveEach claim costs office 4.50 to submit

Insurance Payments vs. Vaccine CostLegend:Greenmax yieldBlueaverage yieldRedmin yieldNet Yield:Insurancepaymentminusvaccinepurchaseprice indollarsEach bar payment for one vaccineAdapted from Gary Freed et al. Pediatrics 2008; 122:1325–1331Paymentsbelow costAdmin fee from 3.87- 26.55

What is Takes to Give a Shot Contract with all health plansCredential site and allprovidersContract with vaccine suppliersOrder and pay for privatevaccine supplySign up for VFCSign up for ASIISOrder VFC vaccine throughstate registry ASIISAccept shipment forvaccine/maintain cold chainRefrigerate vaccineCheck refrigerator twice dailyfor tempsInsure vaccineSchedule vaccine appointmentCheck insurance and VFCeligibilityGather accurate and completeinsurance dataVerify insurance coverage forprivateCheck the patient record bookCheck ASIIS for shot historyScreen patients for what’s neededand contraindicationsCouncil patientGive VIS for every vaccineGet parent signature on eachvaccineDraw up vaccineSwab with alcoholInject vaccineBand-Aid the siteComfort the childUpdate the parent record bookRecord correct diagnosis code torecordRecord cpt to recordRecord NDC and lot number torecordUpdate EHRReport to ASIISInventory vaccine stock inrefrigeratorReport dose by lot number andNDC to ASIIS for VFCFax temp logs to VFCSend record to billingBuild claim in electronic systemall 33 boxesSend claim to clearinghouseand on to payersReceive EOB with payment ordenialRebill 15% of claims for denialAdjust actual payment in billingsystemReport payment to patientRecord in billing systemBill patient directly foroutstanding balance

Problem: Rising Cost of Vaccines 44% percent of privatepractice overhead invaccine stock Offices need to be paid120% of retail cost tocover the expensesCost calculatorsdeveloped by AzAAPThousands of in vaccine

NVAC Recommendations NVAC convened key stakeholders:– Federal, state, and local government– Vaccine manufacturers– Health insurance plans and other payers– Providers (including AAP representation)– Consumers / patients Public sector vaccine purchase for underinsured children in publichealth departments Vaccine administration reimbursement for all VFC-eligible childrenImproving vaccine administration reimbursement for VFC-eligiblechildren (in Medicaid) Supporting delivery of vaccines in the medical home by improvingprivate provider business practices Reducing underinsurance and financial barriers to vaccination ofprivately insured children Vaccine financing activities of federalagencies and offices Vaccine financing activities of state agencies and offices Supporting child & adolescent vaccination in complementaryvenuesAdapted from 2010 Vaccine Congress Presentation NVAC Overview, Megan Lindly

What’s been done 2008 VFC vaccine administration rates for each stateare published on CMS website A CMS workgroup is currently working on a revision toVFC reimbursement caps Temperature monitoring & IIS data-entry costs added in 2009; work continues onantigen-based reimbursement for combination vaccines Lengthened payment terms, prompt-pay discounts etc. AAP & AMA among others creating guidance related to billingand vaccine purchasing pools CDC funding immunization grantees for outreach to increaseVFC providers CDC creating billing guidance for public health 38 immunization grantees received Federal funding to develop billingmechanisms First dollar coverage included in ACAAdapted from 2010 Vaccine Congress Presentation NVAC Overview, Megan Lindly

What Still Needs Work? Increase 317 funding (Decreased) Financial Barriers for the Privately Insured– Voluntary first-dollar coverage of immunization by healthinsurance plans Standards for private health insurance plans may not be included infinal health reform package– Flexible contract language for immunization benefits that canaccommodate updates to schedule or price changes midcontract– Reimbursement policies that factor in all costs associated withvaccine administrationAdapted from 2010 Vaccine Congress Presentation NVAC Overview, Megan Lindly

NVAC Conclusions Increasing numbers and costs of recommendedvaccines have contributed to substantial financialpressure on private (and public) vaccination providers NVAC developed a consensus-driven, evidence-basedset of recommendations to address gaps in public andprivate vaccine financing Progress has been made since September 2008, but allstakeholders must take action to fully implement theserecommendations to preserve the current financingsystem and prevent disease and deathAdapted from 2010 Vaccine Congress Presentation NVAC Overview, Megan Lindly

What to expect with Affordable Care andvaccines

Affordable Care Act Plans must provide first dollar coverage forpreventative services including vaccines. Pressure to decrease Federal spending so thefunding can shift to new coverage. The need for 317 funded vaccines willdecrease as health insurance coverageexpands.

How ACA Impacts Vaccines Fewer uninsured (Medicaid and Market Place) More people with no copays or deductibles forprevention Billing programs in public health More community and school based clinics More focus on adult vaccines Increase payments for Medicaid admin fee(2years)

Remaining problems

Arizona Is Everyone Covered?AZ is 80% small businessand65% of commercially insured in Self Insured Plan65% of ArizonaInsured throughEmployer SelfInsured PlanGrandfathered?

The AZ But Is Everyone Covered?

Frist dollar coverage does not meanadequate reimbursement

Cost of Vaccination

Perspective Annual cost of Lipitor 2,140* Adolescent ER Visit 1,900– Blood work– Chest x-ray– Exam*Prepared by the AARP Public Policy Institute and the PRIME Institute, University ofMinnesota, based on data fromTruven Health Analytics MarketScan Research Databases.

28,430.82 per childhood serieswww.APHA.org

Infectious Disease 53% in 1900 down to 3% in 2010

Vaccines are different Your vaccine protectsothers 50% provided throughpublic funds because ofcost savings Reimbursed understanding orders

Setting Cost VFC buys 50% of the vaccine on the market ACIP makes recommendations based on costvs health care savings HPV girls/boys Mening Prevnar Regulated by the FTC Developed world cost sharing

Making Vaccines is Risky .75 Tax 10 years and 10 billion FDA requirements Huge clinical trails Preservative free Safer vaccines Plants go down Only 4 left