Reforming Medicare Vaccine Coverage to Reduce Barriers to Access

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On June 14, Avalere experts came together with Cynthia Tudor, former Deputy Center Director of the Center for Medicare and Senior Advisor to Avalere, to discuss vaccine coverage and access challenges under Medicare.
Please note: This is an archived post. Some of the information and data discussed in this article may be out of date. It is preserved here for historical reference but should not be used as the basis for business decisions. Please see our main Insights section for more recent posts.

The webinar featured:

The discussion focused on the following topics:

  • The adult vaccine platform and the Medicare coverage framework
  • Medicare vaccine coverage challenges and considerations
  • Reforming Medicare vaccine coverage

The Adult Vaccine Platform and the Medicare Coverage Framework

Today, certain vaccines are covered under Medicare Part B and others are covered under Part D. Vaccines covered under Part B include those for hepatitis B for intermediate and high-risk patients, pneumococcal disease, influenza, and vaccines needed after disease exposure. All other vaccines are covered under the Part D program, including the shingles and Tdap vaccines. This division in vaccine coverage is the result of separate incremental Congressional acts to cover vaccines, including early amendments to Medicare Part B and the subsequent creation of Part D with passage of the Medicare Modernization Act.

Recent data has shown that older adult immunization rates fall well below the national target set by the Healthy People 2020 initiative. Approximately 70% of adults 65 and older were vaccinated against pneumococcal disease compared to the 90% target set by Healthy People 2020. Avalere experts note that cost sharing is a common barrier to vaccine uptake under Medicare Part D.  Cost sharing for vaccines is permitted under Part D, but not Part B.  In a recent Avalere analysis, enrollees in Part D plans with no cost sharing between 2012 and 2016 had a 40%–60% higher shingles vaccine uptake rate than enrollees in Part D plans with cost sharing.

Medicare Vaccine Coverage Challenges and Considerations

Separate, inconsistent vaccine coverage under Medicare has created barriers to vaccine uptake. In addition to cost sharing for Part D vaccines, additional barriers relate to physician Part D billing and reimbursement; storage, handling, and operational challenges; and pharmacist Part B reimbursement. For example, physicians are often not considered “in network” providers under Part D, which can prevent them from accessing beneficiaries’ coverage and cost sharing information. This can lead to patients having to pay the full cost of their Part D vaccines up front and seek reimbursement later, creating a significant burden for patients and providers.

Policymakers are currently considering broader Part B and D reforms, including third-party entity management of Part B drugs, reinsurance contributions (Part D), and coverage standards for Part D. This broader conversation may present opportunities to discuss reforming Medicare coverage of vaccines.

Reforming Medicare Vaccine Coverage

The panelists highlighted 3 interrelated approaches to reforming Medicare vaccine coverage:

  1. Alter Medicare benefit placement of vaccines – Shift all vaccines from B to D, D to B, or cover all vaccines under both B and D;
  2. Eliminate cost sharing for vaccines – Require or incentivize zero-dollar cost sharing for vaccines under Part D; and
  3. Recognize immunization providers – Recognize physicians under Part D and pharmacists under Part B.

Multiple reform strategies can be pursued at multiple levels. Changes could be achieved through legislative reform, a Centers for Medicare and Medicaid Innovation (CMMI) demo, or engagement with the Centers for Medicare and Medicaid Services (CMS) on Part D cost-sharing strategy. A successful approach to any of these strategies would involve robust real-world data analytics to demonstrate the aforementioned vaccine access barriers and the potential impact of reforms.

Cynthia Tudor noted that now is an important time for stakeholders to engage with CMS and policymakers given the current challenges and robust pipeline of vaccines expected for this market. Dr. Tudor emphasized the need to clearly present the public health issue of low adult immunization rates when engaging CMS as well as providing a thoughtful and comprehensive set of policy solutions supported by data.

Listen to the archived webinar here.

Access the webinar slides.

For more information about our vaccines work, connect with us.

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