Push for wellness continues
Editor's note: This article is part of the Medical Economics Business of Health: Immunization resource center.
Immunization rates are so low for adults, the situation has hastened new calls from the Centers for Disease Control and Prevention (CDC) for physicians to assess patient vaccination histories and intervene when appropriate to increase adherence.
The issue is clearly about improving public health, according to new guidelines from the CDC’s Advisory Committee on Immunization Practices, which released its updated guidelines for 2013 recently in an effort to increase adult vaccination rates and offer recommendations for physicians.
In a healthcare system that is shifting toward wellness and prevention as a means of reducing runaway healthcare costs, some work remains when it comes to improving vaccination rates, physicians say.
According to new CDC data, pneumococcal vaccination coverage among adults aged 19 to 64 years at high risk was just 20% overall. Nearly 16% of adults received herpes zoster (shingles) vaccination in 2011, whereas tetanus vaccination is estimated at 64.5% for adults aged 19 to 49 years over a 10-year period.
Although the goal, according to physicians interviewed by Medical Economics, is to make certain patients are protected from the health threats of influenza, pneumococcal, shingles, Tdap, diphtheria, and others, every practice must answer very real business questions. For instance, can you receive adequate reimbursement to make an immunization service viable, and how can you use vaccine administration as a way to engage adults and families about a very serious health threat?
Donna K. Knapp, a practice management consultant with MGMA Consulting, says that physicians simply need to recognize that not many CPT codes command 100% reimbursement from some commercial payers as do immunization services, and it underscores the important role immunizations play in keeping adults and children healthy.
Vaccinations, Knapp says, always will be a necessary service for patients, and they remain a key component to prevention strategies. But assessing their economic viability is another question entirely. Some signs for optimism among public and private payers exist, however.
Over the past few years, improvements in reimbursement of children’s immunizations also have given a boost to the financial realities for family physicians and pediatricians in providing this service, says Jamie Loehr, MD, a family physician at Cayuga Medical Center in Ithaca, New York. In fact, work by the American Academy of Family Physicians and the American Academy of Pediatrics added CPT codes 90460 and 90461, which allow for reimbursement by vaccine components. It means a five-part combination vaccine is reimbursing for five administration codes.
But not every practice or patient panel is alike, experts say, and a service that might be successful for one specialty can be a loss leader for another.
The business of immunization
To either consider offering immunization as a service or evaluate it as an existing service, first assess the need, access for patients in the community, and, very importantly, the costs associated with the service.
The list actually can be quite long, Knapp says. You definitely will need to factor costs for rent, space, labor (including staff benefits, retirement), utilities, vaccine acquisition, equipment, medical and non-medical supplies, storage, and insurance, to name a few.
The practice also will need to evaluate any costs related to special events during the year. She is aware of some primary care practices that conduct Saturday clinics to administer influenza vaccinations. The costs associated with an event might include its promotion, patient scheduling, overtime, etc. The point? Paint a true picture of your practice costs, and then evaluate the level of reimbursement based on your contracts.
So, is it worth it?
It largely depends on the practice and the need of the patient population for immunizations.
According to Loehr, “It is totally worth it from my perspective.” And it is largely based on seeing so many children in his patient panel.
For adult immunizations, Yul Ejnes, MD, immediate past chairman of the American College of Physicians’ Board of Regents and a practicing internist in Cranston, Rhode Island, says the business model has been more challenging.
Some physicians gladly would turn over the responsibility to other providers because of the expenses associated with stocking vaccines versus economic realities of reimbursement.
“Other physicians want to offer it because it is their responsibility, or it is a way to get patients back to the office for wellness checks or deal with other health issues,” Ejnes adds.
Rhode Island’s model
The state of Rhode Island actually removed multiple barriers as it relates to the acquisition of vaccines, Ejnes says, and the move has made it much easier for physicians to manage immunizations.
How does it work? The state of Rhode Island negotiates and purchases vaccines from a variety of manufacturers, and then state officials settle with commercial insurers based on their proportion of the insured population.
“We basically get the vaccine free from the state of Rhode Island, and all we do is charge the insurer for the administration. It eliminates two problems—getting ahold of the vaccine and diversifying the supply. If one manufacturer has to shut down production, then we still have the other sources.”
Reimbursement rates on vaccines themselves traditionally have been just at cost, and in some cases, below cost, Ejnes adds. So it was becoming a loss leader for many physicians. Loehr advises physicians to shop around for price, and he has found success in working directly with vaccine manufacturers to acquire products.
Although the margins are an important consideration, the issue for doctors should be about removing barriers to make certain people are protected from diseases that can be prevented, Ejnes adds. And that’s what it’s all about.
10 proven strategies to improve immunization rates
When it comes to improving immunization rates, what strategies work? The Centers for Disease Control and Prevention (CDC) compiled 10 ways to improve vaccination rates in your practice.
1. Standing order
This written order stipulates that all persons meeting certain criteria (for instance, age or underlying medical condition) should be vaccinated, thus eliminating the need for individual physician’s orders for each patient. How effective is it?
According to the CDC, standing orders are the most consistently effective means for increasing vaccination rates. One hospital study (Crouse, 1994) demonstrated that 40% of inpatients were vaccinated against influenza in hospitals using standing orders compared with 10% of patients in hospitals using physician education only.
2. Computerized record reminders
Computerized record reminders can be efficient and inexpensive, the CDC reports. The downside is that they only target your patients with office visits. “In one practice, pneumococcal vaccination rates of high-risk persons increased from 29% before implementation to 86% following implementation of computerized chart reminders (Payne, 1995),” the CDC says.
3. Chart reminders
The ones that require a simple check mark in an electronic or paper record are the most effective way to facilitate the discussion between physician and patient.
“Reviewing health maintenance inventories with patients requires less than 4 minutes with the patients and quickly becomes part of the physician’s routine,” the CDC states. In one study, influenza vaccination rates increased from 18% before use of a health maintenance flow sheet to 40% with use of the health maintenance flow sheet, the CDC reports.
4. Target-based performance feedback
An effective incentive for many physicians is comparing their vaccination rates for a particular patient population with a goal or standard, the CDC adds. “Some practices encourage friendly competition among physicians, which creates an additional incentive to increase vaccination rates,” the agency reports. In a study (Buffington, 1991), “the percentage of eligible patients vaccinated against influenza at that practice office was 50%, compared to 34% in a control group that did not use the target-based approach. An additional 16% were vaccinated in public clinics, bringing the total percent of patients vaccinated to 66% among patients whose physicians used the target-based approach compared with 50% among control physicians.
5. Home visits
Home visits modestly increase vaccination and counseling for vaccination, the agency says. In the United Kingdom, Nicholson, et al., documented a higher influenza vaccination rate of 20.4% among older persons immobile at home with a specific vaccination program, compared with similar persons with no specified vaccination program.
6. Mailed/telephone reminders
Reminder calls to the patient or a postcard/letter reminding the patient that a vaccination is due or overdue (recall) is a common practice and can increase adherence by some 22%, according to studies on the subject.
7. Expanding access
Expanding access to immunizations can include: reducing the distance patients must travel to receive vaccination services, making administration hours more convenient, delivering vaccinations in settings previously not used, and reducing administrative barriers to vaccination (for instance, drop-in clinics or express lane vaccination services).
When combined, expanding access has been very effective, especially when combined with other methods like patient reminders/recall notices, the CDC says.
8. Patient education
Patient information sheets also are helpful. In fact, they can be distributed in the waiting room. Offer a check-off sheet acknowledging whether they fall into any of the risk groups and whether they wish to receive vaccines during the appointment..
When implemented as a pre-discharge measure in a hospital, pneumococcal and influenza vaccination rates were 75% and 78%, respectively, compared with 0% of patients not given an informational handout (Bloom, 1988). This method also has been used to effectively to increase tetanus toxoid administration (Cates, 1990).
9. Personal health records (PHRs)
Studies have shown that access to personal health records have increased pneumococcal vaccination rates by 20.5%,
“The effectiveness may hinge on the physician’s attitude toward the PHR and receptiveness to patient-initiated care,” the CDC says. “Effectiveness will be maximized when physicians encourage the patients to take initiative, and physicians are willing and able to provide the requested services.”
10. Open up lines of communication
When it comes to vaccination administration, pharmacies also have taken notice. Every state in the country now allows pharmacists to administer influenza vaccine.
Data from the CDC’s National Flu Survey showed that in 2011, nearly 21% of adults were receiving flu shots at a pharmacy, drugstore, or local supermarket.
If you put the competitive questions aside, some questions related to adherence, patient safety, and follow-up communication with physicians need to be addressed, physicians say.
In fact, most doctors simply want to be informed about their patient’s status. Although some pharmacies are excellent about communicating vaccination status with the practice, others are not. Ultimately, the secure exchange of electronic health information will solve this issue, but until then, experts say to take it as an opportunity to reach out to your patients and to local pharmacies to communicate the need and document it.
By the numbers
123 MILLION DOSES
…the number of influenza vaccine doses delivered to providers as of mid-November 2012 for the 2012–2013 season
15.8% OF ADULTS
aged ≥60 years reported receiving herpes zoster vaccination to prevent shingles.
Pneumococcal vaccination coverage among adults aged 19 to 64 years at high risk was 20.1% overall.
In 2011, the proportion of adults receiving any tetanus toxoid–containing vaccination (for instance, Td or Tdap) during the past 10 years was 64.5% for adults aged 19 to 49 years.
Hepatitis A vaccination coverage (≥2 doses) increased among adults aged 19 to 49 years (by 1.8 percentage points to 12.5%) but remained low.
Hepatitis B vaccination coverage (≥3 doses) among all adults aged 19 to 49 years was 35.9%.
29.5% OF WOMEN
aged 19 to 26 years reported receiving ≥1 dose of HPV vaccine in 2011.
Medical Economics Business of Health: Immunization resource center.
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