MANAGED CARE January 2008. ©MediMedia USA
Although federal health agencies support the idea of having pharmacists administer vaccines to their patients, the roadblock continues to be a question of payment
Each year, nearly 90,000 Americans die of infections that can be prevented by vaccination, such as influenza, pneumococcal disease, and hepatitis B, according to the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control & Prevention. Influenza and pneumonia together are the fifth leading cause of American deaths.
Pharmacists can play an important role in lowering that number by administering immunizations, say many health care officials.
Unfortunately most health plans do little to encourage pharmacists to administer vaccinations, even though the idea is advocated by several professional and government organizations, including the American College of Physicians and the Centers for Disease Control & Prevention (CDC). Administration of at least some immunizations, especially influenza and pneumonia vaccines, is legal in at least 44 states, according to the American Society of Health-System Pharmacists.
“Immunization has repeatedly been shown to be cost-effective. In fact, it may be the most cost-effective practice in medicine,” says John D. Grabenstein, PhD, a pharmaco-epidemiologist in the U.S. Army Medical Command who has written extensively about immunization by pharmacists, including the guidelines published by the American Society of Health-System Pharmacists. “But third-party reimbursement policies often do not provide coverage for recommended vaccines, despite the evidence.”
That may change, according to several health plan officials. Beginning Jan. 1, Medicare will pay administration costs ($20 per immunization) for vaccines covered under the Part D drug benefit. Until the beginning of this year, enrollees had to pay for their own shots. And subsequently CMS announced it supports pharmacists as vaccinators.
“Where it is safe to dispense and administer vaccines in a pharmacy, health plans could explore utilization of their own pharmacists as providers of adult Medicare Part D vaccines,” said a recent policy statement to Part D prescription drug plans (PDPs) from Cynthia Tudor, director of CMS’s Medicare Drug Benefit Group.
Until now Part D has allowed PDPs to charge a separate fee for administration. CMS now requires PDPs to include the cost of vaccine administration, along with ingredient cost and any dispensing fee, in their negotiated price for a vaccine. And the agency now forbids PDPs from charging enrollees separate copayments and coinsurance fees for vaccines and their administration.
Medicare Part B
Medicare’s payment policies for the administration of influenza and pneumococcal vaccines will continue under Part B, as will the cost of those vaccines. Hepatitis B vaccine and its administration will be covered under Part B when the vaccine is used to prevent disease in beneficiaries with an intermediate or high risk of hepatitis B infection.
But many recommended vaccines are not covered by Part B. The ACIP recommends, for example, that all adults receive a tetanus booster shot every 10 years. The ACIP immunization schedule does include several products eligible under Part-D, including measles, mumps, rubella, chickenpox, and hepatitis A vaccine — all recommended for patients with diabetes and people over 65.
CMS wants Part D plan sponsors to implement measures to increase access to those vaccines and any others covered by Part D, and that could well mean a greater role for pharmacists, says Abby Block, director of the CMS Center for Beneficiary Choices, in a recent public statement. “We recognize the intrinsic linkage that exists between the vaccine and its corresponding administration, since a beneficiary would never purchase a vaccine without the expectation that it would be administered. We also want to discourage Part D plan sponsors from designing service networks that force beneficiaries to pay the full cost of vaccines up front and seek reimbursement later.”
Adjudication process
The problem with adopting the policy throughout the plan is that “most vaccines on the commercial benefit side are considered a medical benefit and not really part of the prescription drug rider, so the claims process is adjudicated through a different system,” says Taylor. “We are in the process of getting pharmacists set up in our medical systems to pay them for these medical expenses if this administration is recognized within their scope of practice by state [pharmacy] regulating boards. It is not really a cost-saving measure, but more of an increase in access issue.”
Cigna is doing the same, says spokeswoman Lindsay Shearer. “We are reviewing administrative and contractual options to incorporate this within our benefit plans as an option to our members,” she says. “We also cover vaccinations administered by registered nurses in retail clinics that are part of our network, and which may be located in pharmacies. We do believe that it is important for all members to make sure that any immunization becomes part of the member’s official medical record in their physician’s office.”
Efficient record keeping is one reason some physicians have resisted the idea of pharmacists administering vaccines, says a spokesman for the American Medical Association. And opponents fear that the decentralization of immunization administration could erode quality and that people may neglect other health care needs by seeing a pharmacist. But several studies show that pharmacists enhance vaccine delivery. In addition, visiting the pharmacist costs less than going to the doctor, people do it more often, and people trust their pharmacists as providers.
The time has come
“It is definitely an idea whose time has come,” says Beverly Schaefer, a Seattle pharmacist who recently received a grant from the Community Pharmacists Foundation to promote vaccine administration in pharmacies. “Part D will make a difference, I think, on how health plans approach the issue.”
Schaefer says she believes that most physicians would agree that immunization administration in their offices is not cost effective for their practices, especially “at just $20 an immunization. They have to buy the vaccine. There are stock and storage issues, scheduling issues, slow payment from insurers.”
She adds that not all pharmacists are eager to provide immunizations. “They are concerned about the recordkeeping, about potential liability. But on balance, many see this as a potentially valuable service line. And we believe that if more pharmacists were administering vaccines, more people would be vaccinated.”