You can read a transcript of the discussion below or listen to the podcast here.
Richard: Hello and welcome to another episode of Avalere Health Essential Voice in our Start Your Day with Avalere Health podcast series. My name is Richard Hughes and I lead our vaccines team at Avalere. I am joined today by Abby Bownas, Manager of the Adult Vaccine Access Coalition (AVAC), a group of diverse stakeholders committed to improving vaccine access and uptake. Abby is an expert in the vaccines space with an extensive background in vaccine policy and preventive health.
As new adult vaccines come to market, including a future vaccine for COVID-19, continuing the dialogue around the challenges within the vaccine marketplace will be essential to improving access and uptake. In today’s episode, we will explore that marketplace as well as stakeholder support for improving adult vaccine access.
Abby, can you share a brief overview of AVAC and some of issues surrounding adult vaccine access?
Abby: Thank you, Richard, for the opportunity to be here today on behalf of AVAC. As you mentioned, the Adult Vaccine Access Coalition is a diverse group of providers, doctors, nurses, pharmacists, patient groups, public health experts, vaccine innovators, and experts who work on the technology side of vaccines, such as immunization information systems. We came together in 2015 to spearhead policy changes that will increase vaccination rates, saving both lives and money. Adult vaccine rates are far below the Healthy People 2020 goal. They are also much lower than those within our childhood populations. So, AVAC is seeking to improve the immunization infrastructure, eliminate disparities between community vaccine access, remove financial barriers, promote high immunization rates, and more.
Richard: Excellent. So, I want to talk about access issues for specific populations. Medicare vaccine coverage is an issue I have paid close attention to over the years. For those who are not familiar, Medicare coverage of vaccines is unique. The pneumococcal and flu vaccines have been covered under Medicare Part B, Medicare’s physician benefit, since the 1980s. However, all other vaccines, like the shingles or pertussis vaccine, are covered under Medicare Part D, the pharmacy benefit. Beneficiaries are subject to out-of-pocket costs under Part D, which can be a barrier to vaccine uptake since certain vaccines are covered under Part B and not Part D. It also creates issues for the providers administering vaccines.
Abby, could you share your perspective on this access issue and explain some of the efforts underway to resolve it?
Abby: Absolutely. We have both been spending considerable time on the Medicare population, which is important in the vaccine space. Vaccines are essential across the life course, but there is increasing importance for older adults, since the immune system weakens with age and additional factors like chronic illness increase vulnerability.
The discrepancy between vaccines covered in Medicare Part B and Part D creates a financial barrier. When we have first dollar coverage for Part B, it is much easier for patients to receive the vaccines. It also helps if patients can go to their physician or pharmacist and access the full immunization neighborhood. That is very similar to how vaccines get covered in the private insurance marketplace. Under the Affordable Care Act (ACA), all vaccines recommended by the Centers for Disease Control (CDC) are covered with first dollar coverage. With our Medicare population, we still have this discrepancy in cost sharing. That is a disincentive for our Medicare beneficiaries, who may be on limited income. They may choose not to get vaccines like shingles or Tdap, which includes whooping cough (pertussis). We want to make sure that our Medicare population receives all recommended vaccines, so we need to make it as easy as possible.
AVAC has been supporting legislation called the Protecting Seniors through Immunization Act, bill number S1872 in the Senate, and bill number H.R.5076 in the House. We have a great bipartisan group that is working to lead both of those efforts. The legislation would incentivize uptake of those recommended vaccines by providing equity between how vaccines are paid under Medicare Part D and B. It also directs communications and outreach to beneficiaries, boosting the educational efforts around which vaccines adults need and when.
That B versus D coverage is essential in terms of access. On the other side, AVAC is thinking about how we can help providers so they can receive enhanced and timely reimbursement for vaccine administration. We also want to make sure providers can have those important educational and counseling conversations with their patients, since a provider recommendation creates the best opportunity for vaccination. We want to support those conversations.
Those are just a couple of areas in the Medicare space that we are currently working on.
Richard: That is great. Older adults are an important population, especially as we think about COVID-19 and the future. We want to make sure that older adults are prioritized and protected from COVID-19.
Abby: When some of the COVID-19 relief legislation passed earlier this summer, such as the CARES Act, a future COVID-19 vaccine was put under Medicare Part B, which ensures the vaccine is available for Medicare beneficiaries at no cost. That eliminates cost as a factor in whether those vaccines get out.
Richard: Right. A pandemic can really create momentum for that quick change. For years, we made this effort around changes in Medicare coverage for other vaccines. Do you think that the pandemic will accelerate any of those potential changes you were describing?
Abby: I hope so. We have seen several new cosponsors on Protecting Seniors. Our thought is, if we can take certain illnesses out of the equation, we can focus on COVID-19. If you make sure that Medicare beneficiaries have their flu shot and their pneumonia shot, then you are eliminating viruses with similar symptoms and hopefully keep people from going into the health system unnecessarily, allowing providers to focus on the pandemic. It is an essential time to be receiving all the recommended vaccines. We have been having many discussions within AVAC about what it looks like to vaccinate during a pandemic. Are there alternative methods to ensure we are reaching people who may not be going to their physician’s office as they usually would? Those physicians could set up in a parking lot or utilize telemedicine to have those counseling conversations, and a person could go to the pharmacy or clinic to get that recommended vaccine. We are thinking about all the opportunities, especially heading into flu season, which starts in September. The flu is a great opportunity to not only provide the flu vaccine, but also think about the full complement of what a patient may need and capturing those opportunities as they happen.
Richard: You mentioned that the ACA guarantees first dollar coverage for vaccines in the commercial market, but not within Medicare. It also doesn’t apply that requirement to the traditional Medicaid population, where we tend to see a lot of pregnant women. Could you talk about some of the access and coverage barriers there?
Abby: Yes, absolutely. Medicaid expansion states did receive similar coverage, but not non-expansion states. There is a varied map of how vaccines are covered under Medicaid. This creates challenges and opportunities, both in terms of the financial barriers we have been discussing, as well as in how to reach this population. If we can improve access and infrastructure around Medicaid, we can reduce some of the disparities we see in the adult vaccination space. There are socioeconomic, geographic, and racial disparities when it comes to adult vaccines. In Medicaid, low-income communities and communities of color have unequal access to vaccines compared to those in the commercial insurance market, so we want to make sure we are thinking about how to alleviate this. We also know that this population experiences higher rates of chronic conditions such as diabetes and heart and lung disease, which can lead to increased risk of adverse health consequences from vaccine-preventable illness.
On the policy side, the HEROES Act, which is another COVID relief package that has not made it to the finish line yet, includes provisions that would eliminate cost sharing around the COVID-19 vaccine within Medicaid.
On the broader lens, AVAC is working with a Senate office on a bill similar to our Medicare bill that seeks to eliminate cost sharing in Medicaid for all recommended vaccines.
I will also add that when we are talking about Medicaid, we need to consider the education piece and how we talk to that population and their providers. We’ve been trying to pursue materials and provider outreach through the Centers for Medicare and Medicaid Services (CMS) that is culturally and linguistically appropriate to get to those important counseling conversations.
Richard, you also mentioned the maternal vaccine side. We are on the cusp of introducing bills to reach the perinatal population with maternal vaccines. Currently, there are two recommended vaccines for each pregnancy–the flu shot and Tdap. By vaccinating the mother, we are providing some protection to the baby, and they are born healthier. We’re really interested in figuring out how to reach this population both within Medicaid and more broadly.
One of those legislation pieces provides first dollar coverage for pregnant women in Medicaid. There are also some other components to help with quality measures that would be geared toward the prenatal population and some of those counseling conversations that happen in the office. We are excited about those efforts and think they will go a long way to help improve vaccine rates within the Medicaid population.
Richard: Absolutely. Those are extremely important efforts. I was not familiar with all of these, so this is great.
Currently, there are vaccines in the pipeline for C. difficile and for Respiratory Syncytial Virus (RSV). We’ve worked for 50 years for an RSV vaccine and there are many different candidates in the pipeline. As you think about the future and these new opportunities to prevent vaccine-preventable diseases in adults, what are the challenges and what will need to happen to increase access to those vaccines?
Abby: Starting where we left off, those new vaccines should go into Medicare Part D, making it even more important to push through legislation like the Protecting Seniors through Immunization Act. We are working to create a system that will promote those vaccines when they get to market. They will be game changers in the health of our population. I would also add immunization infrastructure, and within that, immunization information systems, as two key components to making sure that our immunization infrastructure can welcome new vaccines.
Immunization infrastructure is all the different pieces it takes to get these vaccines out: vaccine safety, tracking, and education components at the federal, state, and local levels, all working through the CDC, which leads our immunization infrastructure. One core component of that is immunization information systems (IIS). Those are the data and backbone of all our immunizations. They link our providers together. Whether you are getting your vaccines in your doctor’s office, pharmacy, or through a public health department, how are they talking to one another? How are we using that information to see who received which vaccine when? IIS will be key to that. I think we’re doing a wonderful job utilizing those systems in the childhood space and we want to be doing a better job across the life course.
In thinking about the future, the COVID-19 vaccine, for example, could potentially be a multi-dose vaccine. If you receive the vaccine at your provider’s office, you will know that you got your first dose, but you might not know which brand it was. Then you go to your pharmacy for your second dose after 21 or 31 days. We need to make sure the systems are talking to one another so that regardless of where you go, the provider knows what you need.
On the legislative side, we’re looking to modernize and strengthen those systems, and we can do that by funding the overall immunization infrastructure and ensuring that state and local partners have what they need to strengthen the IIS at the same time. That’s where the policy work can get more complex, but it is so important to connect the immunization information systems to everything else we are doing. It is all connected.
Richard: That is extremely helpful. It sounds like a lot of policy change still needs to happen at the federal and state level for those systems to catch up to make the same kind of progress in adult vaccines that we’ve made for childhood vaccines. Abby, is there anything else we have not talked about for adult vaccine access that you would like to showcase today?
Abby: We have covered a lot of ground, which is wonderful. I think one other area–which is a thread between everything that we’re working on–is how we reduce the disparities that exist in adult vaccines. We talked a little about that through the financial barriers in Medicaid. One goal is to improve education on and confidence in vaccines. That can be done through stakeholder groups, as well as our federal partners. We need to work together to combat the false information about vaccines and elevate the science. AVAC is working on several legislative pieces in that area and there is real opportunity to create equal access for everyone. There is a lot keeping us busy at AVAC and we appreciate all that Avalere does with policy and research to help us advocate these cases. The future is bright for vaccines.
Richard: Great! Thank you so much, Abby. We appreciate your partnership. Your insights are invaluable to us and our listeners.
Thank you all for tuning in today to Avalere Health Essential Voice. If you would like to learn more, please stay tuned for more episodes. Download a copy of our 2020 Vaccines Outlook on our website, or visit our COVID-19 intel center at www.avalere.com/covid-19.