# Presentation: 663884

## Old Challenges, New Opportunities in Financing Adult Vaccines

- 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

**Divisions of General Pediatrics and General Internal Medicine, & Gerald R. Ford School of Public Policy, University of Michigan**

## 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*

## What insurance coverage do adults have?

- Bureau of the Census, 2005

|  | # adults
(millions) | % with private insurance | % with public insurance | % uninsured |
| --- | --- | --- | --- | --- |
| Overall | 217.3 | 69 | 26 | 17 |
|  |  |  |  |  |

## What insurance coverage do adults have?

- Bureau of the Census, 2005

|  | # 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 >100% because of coverage by more than one type of insurance in a given year.  % uninsured reflects no coverage at any time in 2004.

## What insurance coverage do adults have?

- Bureau of the Census, 2005

|  | # 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 >100% because of coverage by more than one type of insurance in a given year.  % uninsured reflects no coverage at any time in 2004.

## What insurance coverage do adults have?

- Bureau of the Census, 2005

|  | # 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 >100% because of coverage by more than one type of insurance in a given year.  % uninsured reflects no coverage at any time in 2004.

*Zoster vaccine*

## What insurance coverage do adults have?

- Bureau of the Census, 2005

|  | # 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 >100% because of coverage by more than one type of insurance in a given year.  % uninsured reflects no coverage at any time in 2004.

## What insurance coverage do adults have?

- Bureau of the Census, 2005

|  | # 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 >100% because of coverage by more than one type of insurance in a given year.  % uninsured reflects no coverage at any time in 2004.

*Flu vaccine*

## What insurance coverage do adults have?

- Bureau of the Census, 2005

|  | # 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 >100% because of coverage by more than one type of insurance in a given year.  % uninsured reflects no coverage at any time in 2004.

## What insurance coverage do adults have?

- Bureau of the Census, 2005

|  | # 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 >100% because of coverage by more than one type of insurance in a given year.  % uninsured reflects no coverage at any time in 2004.

*Tdap vaccine*

## 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

## 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

## Coverage of vaccines, by plan financing strategy

|  | Self-insured | Fully insured |
| --- | --- | --- |
| Influenza |  |  |
| Pneumococcal |  |  |
| Hepatitis B |  |  |
| Varicella  |  |  |
| MMR |  |  |

*Plan-level data*

## Coverage of vaccines, by plan financing strategy

|  | Self-insured | Fully insured |
| --- | --- | --- |
| Influenza | 89% | 84% |
| Pneumococcal | 88% | 80% |
| Hepatitis B | 49% | 79% |
| Varicella*  | 39% | 77% |
| MMR* | 40% | 83% |

- *P<.05

*Plan-level data*

## How many adults are potentially underinsured?

|  | All 5 vaccines covered | None of 5 vaccines covered | P value |
| --- | --- | --- | --- |
| Plan financing
   Self-insured
   Fully insured
 |  |  |  |
| Mean plan
  deductible |  |  |  |
| Preventive 
   care cap |  |  |  |

*Plan-level data*

## How many adults are potentially underinsured?

|  | 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 |

*Plan-level data*

## How many adults are potentially underinsured?

|  | 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 |

*Plan-level data*

## How many adult enrollees are underinsured?

- For all 5 vaccines:
- For influenza vaccine and PPV23:

## How many adult enrollees are underinsured?

- For all 5 vaccines:
- 29% underinsured
- For influenza vaccine and PPV23:
- 22% underinsured

## 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

## Who is underinsured for vaccines?

|  | Underinsured for influenza and PPV23 | Underinsured for all 5 vaccines | Distribution of enrollees overall |
| --- | --- | --- | --- |
| Employer size
   <100
   100-499
   ≥ 500 |  |  | 
33%
11%
56% |
| Plan financing
   Self-insured
   Fully insured |  |  | 
62%
38% |

## Who is underinsured for vaccines?

|  | Underinsured for influenza and PPV23 | Underinsured for all 5 vaccines | Distribution of enrollees overall |
| --- | --- | --- | --- |
| Employer size
   <100
   100-499
   ≥ 500 | 
28%
10%
62% | 
28%
10%
62% | 
33%
11%
56% |
| Plan financing
   Self-insured
   Fully insured | 
73%
27% | 
74%
26% | 
62%
38% |

## Who is underinsured for vaccines?

|  | Underinsured for influenza and PPV23 | Underinsured for all 5 vaccines | Distribution of enrollees overall |
| --- | --- | --- | --- |
| Employer size
   <100
   100-499
   ≥ 500 | 
28%
10%
62% | 
28%
10%
62% | 
33%
11%
56% |
| Plan financing
   Self-insured
   Fully insured | 
73%
27% | 
74%
26% | 
62%
38% |

## Opportunities to Address Underinsurance

- In health plans
- By motivating public demand for vaccines

## Employers and Insurers as a Constituency

- Current primary constituency for vaccine information:  health care providers
-  information to patients
-  information to employers and insurers

## 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

## Why Should Employers and Insurers Listen?

- Direct cost implications
*Health services utilization*
*Pharmacy utilization*

## Why Should Employers and Insurers Listen?

- Direct cost implications
*Health services utilization*
*Pharmacy utilization*
- Indirect cost implications
*Absenteeism*
*Presenteeism*

## Why Should Employers and Insurers Listen?

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

## 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?*

## 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*

## Promoting Prevention in Consumer-Driven Plans

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

## 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

## 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?

## 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*

## 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

## 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

## 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

## 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

*In summary . . . *

## 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*

## Underinsurance: Challenges for the Future

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

## Underinsurance: Challenges for the Future

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

## 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

## 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?*

## Promoting Flu Vaccine for Elders viaDTC-style Campaign: Cost-Effectiveness

- Promoting Flu Vaccine for Elders viaDTC-style Campaign: Cost-Effectiveness