The COVID-19 pandemic has exacerbated existing challenges to adult and child immunization uptake in the US. With flu season expected to begin in October, public health experts outline the potential dangers if peaks of flu and COVID-19 occur simultaneously: an overwhelmed health care system, strained testing capacity, and a potentially reduced ability to catch and treat both respiratory illnesses effectively. As children return to schools and COVID-19 cases are on the rise in more than half of the US, the need to better understand the impacts of COVID-19 on routine and seasonal vaccinations for adults and children is timely and valuable to healthcare stakeholders.

To that end, Avalere conducted a survey in August 2020 to better understand providers’ perspectives on vaccination rates and associated barriers to immunization within the context of COVID-19. The survey had 2 main objectives:

1. to understand what pressures (financial and otherwise) associated with the COVID-19 pandemic may affect providers’ willingness and capabilities to offer their normal (not COVID-19) immunization services for their patients (e.g., seasonal flu, pneumococcal, and other routine childhood vaccines, where applicable)
2. to ascertain if an increase in vaccination administration fees would help maintain high levels of immunizations during a continued global pandemic

The findings from this survey can help inform and contextualize policy maker efforts to increase vaccine uptake, particularly in light of a recent Centers for Medicare & Medicaid Studies (CMS) proposal that, if finalized, would increase provider reimbursement for vaccine administration under the Medicare program.

COVID-19 Pandemic Impact on Provider Vaccine Administration Behavior

Research suggests that COVID-19 has had a substantial impact on declining adult and childhood routine and seasonal vaccination rates in 2020. For adults ages 65 years and older, rates have dropped 83% compared to last year, and in individuals age 19 to 49 years there were declines of more than 60% (comparing rates from March–May 2019 and March–May 2020).¹ Additionally, in a study conducted through the Centers for Disease Control and Prevention, fewer than half (49.7%) of infants reaching age 5 months in Michigan were up to date on all recommended vaccines in May 2020, compared to about two-thirds (66.6%, 67.4%, 67.3%, 67.9%) during the past four years.²

Methodology of Survey Design

With this framing in mind, Avalere developed a 20-item survey using the advice of vaccines and public health experts based on current literature regarding barriers to vaccine administration, specific COVID-19 challenges, and the effects of current reimbursement levels.

Avalere surveyed physicians, allied health professionals, and practice administrators across internal medicine, family medicine, pediatric, and geriatric practices. The 214-respondent sample intended to roughly mirror the national distribution of primary care practitioners by specialty, US geographic region, and urban/suburban/rural locations. To participate in the survey, respondents had to meet certain parameters and threshold requirements.

Reported Impact of COVID-19 Pandemic on Practices

Avalere’s analysis of survey responses highlighted the impact of COVID-19 on day-to-day operations for healthcare professionals across the US. Over 90% of respondents indicated the COVID-19 pandemic had led to increased operating costs and revenue loss due to 1 or more factors such as office shut-downs, patient cancellations, costs of maintaining sufficient protective equipment, and other care delivery changes. Seventy-five percent (161/214) of respondents expressed interest in implementing 1 or more new care delivery arrangements (e.g., clinic remodels, tent or parking lot administration sites) to facilitate immunizations during the COVID-19 pandemic. However, few sites have undertaken these modifications to date. Ninety-six percent (205/214) of respondents indicated that cost considerations were a “somewhat” or “very important” consideration in whether to undertake changes such as alternative vaccination sites and office modifications. One selected participant commented that “we estimate that after 4 months of COVID pandemic problems that more than 50% of our patients are behind in all of these categories of vaccinations.”

Of note, respondents also pointed to COVID-19 as a significant perceived reason for the decline of vaccination rates in early 2020: 60% (129/214) of respondents indicated they administered fewer vaccines in the first 6 months of 2020 compared to the same time period in 2019. The weight attributed to the COVID-19 impact on vaccination rates varied across regions (see Table 2), but among respondents who did experience a decline, 95% (123/129) reported that COVID-19 was a major reason for the decline.

*60% (129/214) of survey respondents indicated that their clinic administered fewer vaccine doses in the first six months of 2020 compared to the first six months of 2019. Overall, more respondents from the Northeast and Southeast regions saw a decline in vaccinations in early 2020 compared to early 2019.

Geographic variation also highlights the varying levels of concern regarding reduced vaccination rates in the 2020 flu season. Twenty-five percent (53/214) of respondents reported they anticipate administering fewer vaccines in August 2020 through the end of the flu season compared to this same period in 2019. Respondents in the West are most concerned about potential decline.

In addition to the challenges to vaccination posed by the pandemic, an increase in telehealth also likely contributed to reduced in-person visits and thus reduced vaccinations. Eighty-one percent (174/214) of respondents stated they switched to or substantially increased telehealth visits due to COVID-19.

Reported Interest in Increasing the Vaccine Administration Fee

One potential policy solution to help mitigate the pandemic’s impact on routine and seasonal vaccination is increasing reimbursement for vaccine administration.

While multiple barriers to vaccinations were reported, more than 80% (175/214) of respondents indicated that an increase in vaccine administration fees would aid sites in overcoming barriers posed by the COVID-19 pandemic. Of those 175, 66% (115) stated that if the CMS offered an increase in vaccination administration fees for Medicare/Medicaid patients, it would “help us a lot” in overcoming barriers, and 33% stated that it would “help us some.” Overall, practice sites serving adult and pediatric patients agreed that a vaccine administration fee increase of 50%–100% would be needed to overcome barriers created and exacerbated by the COVID-19 pandemic. These findings are particularly noteworthy as policymakers actively consider strategies to increase provider payment for vaccination services. Specifically, in the recently proposed CY 2021 Medicare Physician Fee Schedule (MPFS), the CMS included a provision that would cross-walk the vaccine administration codes with a separate, non-vaccine related code with a higher valuation. If finalized, this change would result in an approximate 120% increase in Medicare provider reimbursement for vaccine administration starting in January 2021.

Conclusion

The COVID-19 pandemic continues to disrupt the day-to-day operations of healthcare clinics across the US. With the arrival of flu season, healthcare stakeholders are expressing significant concerns with regard to ensuring high vaccination rates for routine and seasonal vaccines for both adults and children. It will be important that providers are able to implement alternate vaccination approaches that ensure a high level of safety and acceptability for patients and providers. Further, while provisions in the proposed CY 2021 MPFS would increase reimbursement for vaccine administration under Medicare in 2021, it is important to consider how to address challenges in other markets (e.g., Medicaid) where such changes have not yet been contemplated. Policymakers, providers, and payers should also consider other necessary mechanisms to address ongoing barriers to vaccination, such as patient and caregiver hesitancy to seek routine and seasonal vaccinations for themselves or their children.

Funding for this research was provided by Sanofi. Avalere maintained full editorial control over the content.

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Notes

1. M. Frellick, “Vaccine Rates for All Ages Drop Dramatically During COVID-19,” Medscape, June 8, 2020.

2. C. Bramer et al. “Decline in Child Vaccination Coverage During the COVID-19 Pandemic—Michigan Care Improvement Registry, May 2016–May 2020,” Morbidity and Mortality Weekly Report 69 (2020):630–631.