Calling the Shots Immunization Finance Policies and Practices (2000) / Chapter Skim
Currently Skimming:
Financing Vaccine Purchase and Delivery
Financing Vaccine Purchase and Delivery
Pages 71-102
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From page 71... ...
An additional and relatively unique aspect of immunization services is that, unlike many types of health care, their provision is the subject of widely accepted, evidence-based practice guidelines for both children and adults, promulgated and updated by CDC's Advisory Committee on Immunization Practices (ACIP) (see Figure 1-1 and Table 1-3 in Chapter 1~.
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From page 72... ...
Vaccine purchase and service delivery are essential features of the national immunization enterprise, and immunizations are optimally provided within the context of an ongoing primary care relationship. General health care financing provided through employmentbased and other private insurance, Medicaid, the State Children's Health Insurance Program (SCHIP)
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From page 74... ...
The first three sections of this chapter examine immunization coverage and payment policies under private health insurance; Medicaid, SCHIP, and VFC; and Medicare. The fourth section reviews vaccine purchase grants under Section 317, while the fifth examines state vaccine purchase policies.
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From page 75... ...
Employers that self-insure are generally exempt from state insurance regulation under the federal Employee Retirement Income Security Act (ERISA) .3 Approximately 50 million privately insured individuals are covered by self-insured plans, and this limits the reach of state insurance laws or regulations governing the coverage of pediatric vaccines (Copeland and Pierron, 1998; Polzer, 2000~.
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From page 76... ...
This "maintenance-of-effort" provision was aimed at preventing employer-sponsored plans from reducing coverage following enactment of the VFC program. While the statute does not require a particular level of coverage and does not specify standards regarding deductibles and cost sharing, it establishes some federal standards with respect to childhood immunizations.5 There are few data available on insurance practices with respect to immunizations.
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From page 77... ...
MEDICAID, VACCINES FOR CHILDREN, AND STATE CHILDREN'S HEALTH INSURANCE PROGRAM Medicaid and Early and Periodic Screening, Diagnosis, and Treatment Program Medicaid, the nation's largest public insurance program for lowincome and medically indigent persons, covered an estimated 31 million people in 1998, more than half of whom were children (Health Care Financing Administration, 2000c, 2000d)
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From page 78... ...
The law provides that, as a condition of receipt of vaccine under VFC, states must agree to maintain their insurance laws governing immunization coverage at 1993 levels.~4 The VFC program does not change the states' basic obligation to cover all ACIP vaccines for Medicaid children. Significant delays can occur,
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From page 79... ...
To the extent that states use their SCHIP allotments to expand Medicaid, all Medicaid coverage requirements apply. As with other Medicaidcovered children, those whose enrollment is purchased with federal SCHIP funds are entitled to the full EPSDT benefits, including vaccines purchased through the VFC program.
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From page 80... ...
Program FY 1994a FY 1994 FY 1995 FY 1995 FY 1996 FY 1996 FY 1997 Enactedb ActualC Enacted Actual Enacted Actual Enacted VFC Program Vaccine purchase 20.9 20.9 412.0 213.8 349.3 254.9 498.6 Operations 3.8 3.8 45.3 29.8 24.7 24.7 25.4 Total 24.7 24.7 457.3 243.6 374.0 279.6 524.0 Medicaid 200.0 140.0 140.0 60.0 60.0 65.0 TOTAL 224.7 597.3 383.6 434.0 339.6 589.0 aIn FY 1994, $80 million was awarded for phase 1 operations and vaccine purchase. bThe enacted level is the amount requested in the president's budget.
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From page 81... ...
Figure 3-2 shows the combined potential reach of Medicaid, the VFC program, and SCHIP. Assuming full coverage of all eligible children, Medicaid and SCHIP would reach about one-third of all American children aged 18 and underlit The addition of VFC entitlement for nonMedicaid children increases by another 6 million the number of children TABLE 3-4 State Children's Health Insurance Programs, 2000a Type of Program Number of States Medicaid Expansion Only Separate SCHIP Combination Program 18 plus District of Columbia (16 operational for full year)
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From page 82... ...
entitled to vaccine coverage as a matter of federal law.~9 Thus as of 1999, federal policies allowed for the potential coverage of roughly 30 million children for immunization services. SCHIP enrollment had reached a total of almost 2 million children by September 30, 1999, double the number covered in the first full year of the program, calendar year 1998 (Health Care Financing Administration [HCFA]
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From page 83... ...
Because children enrolled in freestanding SCHIP programs are "insured" and therefore not eligible for VFC vaccines, the capitation rates paid to SCHIP plans ostensibly cover both the cost of purchasing required vaccines and the cost of administering them, unless the state makes other arrangements (see Box 3-2~. In California, a state with a combination SCHIP program, some providers argue that the capitation rates in the freestanding SCHIP plans are set too low to compensate them for vaccine purchases, and some capitated providers have referred patients to public health clinics to receive free vaccinations (Fairbrother et al., forthcoming)
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From page 84... ...
Medicaid but < 50% over Medicaid (65-85%) eligibility levels who are uninsured and ineligible for Medicaid aThe Advisory Committee on Immunization Practices establishes general vaccine schedule recommendations and then prepares a separate resolution for coverage through the VFC Program.
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From page 85... ...
Because of the scale of the VFC program and the narrow statutory definition of administrative costs for that program, states must draw upon Section 317 grants and state revenues to implement the VFC effort fully in public and private health care settings.
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From page 86... ...
. Some have argued that Medicare administration fees are too low to compensate physicians adequately for the costs of storing and administering vaccines, and that these low fees contribute to low immunization coverage rates among beneficiaries (Poland and Miller, 2000~.
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From page 87... ...
Pneumococcal vaccine coverage rates for high-risk adults aged 18-64 were 28 percent for those with Medicare, 12 percent for those with private insurance, and 10 percent for those without insurance (see Table 3-6~. The number of adults aged 18-65 who are at high risk of complications from influenza and pneumococcal disease, for whom immunization is strongly recommended, is roughly 26 million (11 percent of those aged 18-44 and 24 percent of those aged 45-64 have chronic conditions that put them at risk)
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From page 88... ...
88 U U o U ON be o u MU V)
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From page 89... ...
Finding 3-3. The Medicare program has become the single most important source of financing and service delivery for adult immunization efforts over the past decade, and coverage rates for influenza and pneumococcal vaccines have shown significant increases during this period.
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From page 90... ...
Under the category of program operations, CDC develops national goals, plans and assesses strategies for reaching these goals, negotiates consolidated vaccine purchase contracts, provides surveillance of vaccine-preventable diseases and technical assistance to state and local health agencies, and conducts vaccine safety activities. CDC also engages in international eradication efforts targeting polio, measles, and other vaccine-preventable diseases, which account for a growing share of Section 317 funding.
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From page 91... ...
The Section 317 vaccine purchase program allows states to purchase vaccines for administration to disadvantaged populations in a timely manner and to avoid missed opportunities when no other coverage is available to support immunization services. Section 317 infrastructure grants also provide funds for service delivery in the public health sector, and afford state immunization programs swift access to
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From page 92... ...
As the scope of required immunizations has grown and costs have increased, however, serious tensions have emerged that warrant greater scrutiny. Prior to VFC, private health plans and families paid for most of the immunizations provided in private health care settings, although some private providers immunized children covered by Medicaid.
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From page 93... ...
States are highly variable in the extent to which they use state revenues for vaccine purchase. Estimating the state-funded share of publicly purchased vaccines in each state from records of expenditures for all vaccines purchased under federal discounted price contracts yields the following results: · 24 states plus the District of Columbia provide less than 10 percent of publicly purchased vaccines in their jurisdiction, · 16 states contribute between 10 and 30 percent of publicly purchased vaccines, and · 10 states contribute 30 percent or more of all publicly purchased vaccines.
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From page 95... ...
VFC Only The VFC program provides federally purchased vaccine for all eligible children (Medicaid enrollees aged 18 and younger, uninsured children, Native American children) at participating public and private sites.
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From page 96... ...
In this case, Section 317 funds vaccines for non-VFC-eligible children served in public settings, and state revenues fund vaccines for underinsured children seen in the private sector. Sixteen states and the District of Columbia have enhanced VFC programs (information provided by CDC)
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From page 97... ...
The way states used these Medicaid savings was highly variable. In response to the 1999 IOM state survey, 25 states said that Medicaid payment levels for vaccine administration or other pediatric care had increased, but only 4 states identified those increases as being related to savings from VFC (in one state, for example, the vaccine administration fee increased because the state Medicaid agency misinterpreted HCFA's maximum allowable reimbursement as the minimum)
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From page 98... ...
The problem is most pronounced for universal purchase states: When the ACIP makes a recommendation for a new vaccine and they include it in the VFC program, then they are in effect pushing and controlling state budgets for universal purchase states. They do not take into consideration some very specific situations that exist for states.
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From page 99... ...
Complex eligibility criteria and coverage conditionsfor the multiple federal and state programs supporting vaccine purchase and delivery have left gaps and omissions in thefinancial coverage of immunizations for children and adults. States respond to these residual needs by continuing to provide free vaccines in public health clinics,financed by a combination of Section 317funds and state revenues.
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From page 100... ...
State investments in immunization services appear to have increased during the 1990s, but these increases have not been at the same dramatic levels seen with the creation of VFC or the early growth in Section 317 budgets. States were more likely to extend their efforts through their investments in expanded Medicaid coverage, both by increasing vaccine administration fees and by broadening the base of clients served by Medicaid plans.
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From page 101... ...
§1396s. The VFC program was originally proposed as the initial phase of the Clinton Administration's national health care reform proposal; this is reflected in another provision of the law, which would terminate the VFC program at the point at which federal law provides for immunization services for all children as part of a "broad-based reform of the national health care system" (§1928(g)
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From page 102... ...
code, or payment weight, for vaccine administration. Like other physician services included in the RVS-based Part B payment system, the actual payment amount for vaccine administration varies according to a Geographic Practice Cost Index that distinguishes 360 localities nationally according to their relative medical practice input prices.
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