# Presentation: 071568

## NVPO-NVAC Response toFinancing Vaccines in the 21st Century:Assuring Access and Availability 

**Institute of Medicine Report - 2003**
**Alan R. Hinman, MD, MPH**
**June 28, 2004**

## Recommendations – 3a

**The National Vaccine Program Office should convene a series of stakeholder deliberations on the administrative, technical, and legislative issues associated with a shift from vaccine purchase to a vaccine mandate, subsidy, and voucher finance strategy.  In addition, the Centers for Disease Control and Prevention (CDC) should sponsor a postimplementation evaluation study (in 5 years, for example).**** **

## Recommendations – 3b

**CDC should also initiate a research program aimed at improving the measurement of the societal value of vaccines, addressing methodological  challenges, and providing a basis for comparing the impact of different measurement approaches in achieving national immunization goals.**** **

## Response to IOM report

**Wall Street Journal editorial**
**Briefing at American Enterprise Institute**
**Forum at Partnership for Immunization**
**NVAC stakeholder interviews**

## Initial “environmental scan” of stakeholders

**30-60 minute telephone interviews conducted Sept. 25 – Oct. 3**
**Interview team**
**Bruce Gellin, NVPO**
**Alan Hinman, NVAC**
**Nicole Smith, NIP/CDC**
**Interviews were informal, “not for attribution”**

## Stakeholders interviewed - 1

**Vaccine companies**
**Aventis**
**Baxter**
**Chiron**
**GlaxoSmithKline**
**Merck**
**Wyeth**
**Federal government agencies**
**CMS**
**HRSA**

## Stakeholders interviewed - 2

**Public Health Agency organizations**
**AIM**
**ASTHO**
**NACCHO**
**Provider organizations**
**AAFP**
**AAP**
**ACP**
**Payers/insurers**
**AAHP**

## Initial overall reactions - 1

**Universal commendation to IOM for:**
**Highlighting the value of vaccines**
**Highlighting the need to vaccinate adults as well as children**
**Attempting to ensure access to vaccines by all children**
**Identifying factors contributing to instability in vaccine research, development, production, supply**

## Initial overall reactions - 2

**Recommendations propose such sweeping changes they are still considering implications**
**Report does not make clear its relationship to “Calling the Shots” (IOM 2001) and therefore it is not clear what the role of public health agencies will be**
**Report not clear on whether its recommendations would apply to all adults or only high-risk adults**

## Initial overall reactions - 3

**Report insufficiently acknowledges achievements/strengths of current system**
**Report insufficiently identifies non-price factors responsible for reduction in number of manufacturers, e.g.**
**Mergers**
**Manufacturing problems**
**Regulatory environment**
**Is the situation as desperate as described?**

## Mandate/subsidy/voucher - 1

**Unconvinced this would provide incentives to manufacturers**
**Would require major legislative changes at national and state levels**
**Recommended changes require a lot of things to happen at the same time.  How likely is this in current political/economic climate?  Mandate, subsidy, and voucher are not popular words at present**
**Are there successful models of how and whether this approach would work?**

## Mandate/subsidy/voucher - 2

**How would the system work?**
**Who would oversee the whole thing?**
**How much would it cost?**
**What would be administrative/financial burden on practitioner?**
**How to ensure comparable coverage in different states (e.g., Medicaid)?**
**How to maintain the close public health – practitioner contacts VFC has fostered?**

## Mandate/subsidy/voucher - 3

**Merely providing financing unlikely to raise adult immunization levels markedly**
**Wouldn’t subsidy be subject to same uncertainty of appropriations as 317?**
**What about vaccines without “substantial spillover effects” (e.g., herd immunity)?**

## Mandate/subsidy/voucher - 4

**Calculating societal benefit**
**Who would establish the standard for analysis?**
**Would this adversely affect manufacturers’ R & D?**
**Given long lead time for vaccine R & D and imponderables (e.g., # doses required), would results be accurate?**
**Does this not establish a new means of price-fixing?**
**Are there successful models of how and whether this approach would work?**

## ACIP composition and role

**Mixed reactions**
**Some thought additional perspectives would be useful**
**Others thought ACIP should retain scientific role and another body should make economic analyses/decisions**

## Provisional conclusions - 1

**There is a need to assure access to vaccines for all children and adults**
**Coverage is still sub-optimal, particularly in adults**
**Sufficient incentives should exist so manufacturers will continue to develop and produce vaccines**
**Skepticism that recommended approaches will provide those incentives or improve immunization levels in children and adults**

## Provisional conclusions - 2

**Concern about undertaking dramatic shift from present system to unproven new system**
**Concern about lack of detail about how proposed new system would operate**
**Concern about cost of new system**
**Is the system sufficiently broken to require this level of “fix”?**

## Provisional conclusions - 3

**Improvements in current system might go a long way to achieving goals**
**Expanding VFC to all underinsured children in all settings**
**Removing price caps**
**Giving providers choice of vaccines**
**Regulatory harmonization**
**Encourage expansion of health plan benefits**

## Next steps

**Convene public meeting June 28-29 with multiple stakeholders**
**Pros and cons of options considered**
**Additional options that should be considered**
**Which option they support and why**
**Report back to NVAC at October 5-6 meeting**