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    Patients, physicians forgo adult vaccines over cost and coverage concerns


    The ACA’s impact on vaccines

    While potential changes to the American healthcare landscape leave the future in question, under the ACA, non-grandfathered private health insurance plans were mandated to cover vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) without copays when administered by in-network providers. The ACA did not address, however, payments to providers for vaccine purchase and administration, according to the report.

    The ACA also temporarily increased Medicaid reimbursements for vaccine administration, but did not mandate that state agencies participate and as a result, several states did not cover all of the ACIP-recommended vaccines.

    “Overall, the ACA has improved access for adult patients to receive vaccines by expanding health insurance coverage for millions of Americans and by mandating several private insurance plans to cover ACIP recommended vaccinations,” said Laura P. Hurley, MD, a primary care physician at Denver Health and lead author of the study. “However, even with these vaccine-specific provisions of the ACA, gaps remain in the financial infrastructure of adult vaccines in terms of prohibitive costs for patients and perceived insufficient reimbursement for physicians, particularly from public payers.”

    Financing adult vaccination is still complicated, Hurley said, particularly when it comes to patients with Medicare Part D. And it’s not just patients who have a difficult time understanding their benefits—it’s clinicians, too.

    “Clinicians should have an understanding of which adult vaccines are covered by Medicare Part B versus Medicare Part D to best direct patients where they should receive vaccines,” she said.

    Medicare.gov offers resources on coverage levels under the various Medicare options.

    Some public health departments also have resources, in the form of 317 funds, that can be used to vaccine uninsured or underinsured adults, Hurley said, so clinicians can refer patients to their local health departments as one option. Vaccine manufacturers may also offer assistance programs that can defer the cost of adult vaccines.

    Hurley said she hopes her research brings light and new solutions to the problematic financing of adult vaccines. One option, she says, could be to create a program similar to the Vaccine for Children program, a federally funded program that provides vaccine coverage to children who might not otherwise be vaccinated due to inability to pay. The program claims to have prevented 322 million illnesses since it was founded in 1994.

     “I would welcome discussions of an equivalent program for adults,” Hurley said.


    Rachael Zimlich, RN
    Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare ...


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