Transcript The Challenge of Adult Immunization California Adult Immunization

The Challenge of Herpes
Zoster Immunization
Litjen (L.J) Tan, MS, PhD
Director, Medicine and Public Health
American Medical Association
Herpes Zoster (HZ)
• Reactivation of VZV results in zoster (shingles).
• The cutaneous eruption of zoster occurs in a
dermatomal distribution.
• Up to 800,000 cases of zoster occur annually in
the United States.
• Advanced age and decreased cell-mediated
immunity are defined risk factors.
• Zoster is characterized by pain that can
negatively affect activities of daily living.
• Postherpetic neuralgia is the most common
complication.
Straus SE, Oxman MN. In: Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatology in
General Medicine, 5th ed. Vol 2. New York, NY: McGraw-Hill; 1999:2427-2450.
Schmader KE. Clin J Pain. 2002;18:350-354.
Katz J, Copper EM, Walther RR, Sweeney EW, Dworkin RH. Clin Infect Dis. 2004;39:342-348.
So Why Is HZ Vaccine So
Under-utilized?
• Vaccine coverage of 1.9% in 60-and-older
• Economic burden for the patient
• Is there sufficient patient demand?
• Economic burden for the physician
• Difficult vaccine to store
• Put patients on waiting list until sufficient number to
justify ordering vaccine
• Complex payment processes for the physician
• Reflects general problems with adult
immunization apathy in the United States
Economic Burden for the
Patient
• Most expensive vaccine for the 60-andolder
• Average wholesale price of $194
• Retail prices >$200
• While those over 60 may be aware of the
vaccine, most are not aware of its cost
• Significant number may defer immunization
when they discover the cost
• For the physician, this is a difficult barrier as
many do not know what the cost to the patient
may really be (private payer vs. Medicare, etc)
• Results in inequitable access to HZ vaccine
Economic Burden for the
Physician
• Many physicians serving those 60-andover are not accustomed to immunizing
• Inventory management for the physician
is complex
• Stocking an expensive frozen vaccine
presents unique challenges – vaccine comes
in 10-dose shipments
• Do distributors carry the vaccine
consistently?
• Physicians may create a waiting list before
ordering vaccine
Complex Payment Processes!
• Is it Medicare Part D, or is it Medicare
Part B?
Medicare Part D!
Medicare Part D
• Administered by individual drug plans that
contract with pharmacies (in-network). Pharmacy
bills the plan and charges the patient appropriate
co-pays
• Co-pays vary across plans! Average – 25% of
the cost
• Not designed to pay for vaccines provided in
physician’s office with variability across plans
(out-of-network!)
• Patient pay full amount and then submits claim form
• Other plans may have special procedures
• Vaccine administration fee covered
BUT…significant variability with no hard
standard enforced by CMS
• Expects Part D plans to take Part B admin fee
structure in conisderation
Medicare Part D
• The Donut Hole!
• $250 deductible;
• 25% co-insurance on formulary drugs
between the deductible and initial coverage
limit;
• $2250 initial coverage limit on total drug
expenses;
• $3600 out-of-pocket threshold, reached after
total drug costs equal $5100;
• Catastrophic coverage of no more that 5%
co-insurance for formulary drugs
Addressing the Medicare Part
D Challenge
• Significant administrative burden placed on the patient and
physician
• Physician calls in prescription to specialty pharmacy who
ships vaccine to physician and bills plan and patient
• Missed opportunities?
• Patient needs to identify carrier. Physician needs to follow
through
• Physician writes prescription and sends patient to retail
pharmacy for vaccination
• “Brown bagging” not encouraged but will happen
• Documentation challenging
• Pharmacy may not carry vaccine; or may not administer
leading to missed opportunities
• Not all patients may be comfortable being vaccinated in a
pharmacy
Addressing the Medicare Part
D Challenge
• Find methods to facilitate out-of-network solutions
• Part D plan can provide patients with specific information
to deliver to the physicians so that physician can directly
bill the plan
• Facilitate web-based electronic billing
• Pays cost of vaccine without imposing new administrative
burdens
• Allows patient to receive vaccine immediately reducing
missed opportunities
• eDispense: http://enroll.edispense.com
• Physician needs to enroll and the patient’s plan needs to
also be enrolled
• Move adult vaccines into Medicare Part B
What About Private Insurance?
• Through the employer’s health plan
• Plan needs to confirm that HZ vaccine is
covered
• When covered, vaccines are reimbursed by
private health insurance as a medical benefit
• OR
• Through the retiree health benefits
• If 65-or-over, then Medicare is primary payer
and private insurance becomes secondary
Summary
•
Challenge with HZ vaccine is not necessarily
about education of the value of the vaccine
Need to simplify both in-network and out-ofnetwork options for paying for the vaccine and its
administration
Need to address issue of the Medicare Part D
donut hole for patients
Need to continue to encourage private payer
coverage
Seek Help!
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The Merck Vaccine Reimbursement Support CenterTM
(MVRSC) 1-800-REIMBVAX (1-800-734-6282) offers
assistance and information when seeking payer
reimbursement for ZOSTAVAX®