Increases in the number and cost of vaccines routinely recommended for children and adolescents have raised concerns about the ability of the current systems for vaccine financing and delivery to ensure that all children and adolescents have access to all routinely recommended vaccinations without financial barriers. The National Vaccine Advisory Committee (NVAC) was chartered in 1988 to advise and to make recommendations to the director of the National Vaccine Program and the Assistant Secretary for Health at the US Department of Health and Human Services on matters related to the prevention of infectious diseases through vaccination. In October 2006, NVAC established a Vaccine Financing Working Group to explore approaches for child and adolescent vaccine financing. The Vaccine Financing Working Group was charged with establishing a process for obtaining stakeholder input regarding challenges to creating optimal approaches to vaccine financing in both the public and private sectors. The goal of this process was to develop recommendations to ensure that all children and adolescents have access to all routinely recommended vaccinations without financial barriers.
The NVAC considered several overarching principles in formulating its recommendations. First, vaccine-preventable diseases are not constrained by geographic boundaries, and policies on vaccine financing should be national in scope. Second, vaccine financing solutions should address near-term problems with vaccine financing and should anticipate continued changes in recommended child and adolescent immunization schedules and the health care delivery system. Third, because vaccine financing problems are multifactorial, their solutions also should be multifactorial and all stakeholders will need to participate in implementing the solutions. Finally, because it is difficult to achieve uniform national implementation of policies that require state-based legislative or budgetary action, legislative or policy actions at the federal level, when appropriate, are recommended for achieving vaccine financing goals.
The background for these recommendations is presented in a literature review of the current US systems for vaccine financing and delivery and challenges in the financing of vaccines for children and adolescents.1 This review includes results from several original research studies initiated specifically to provide the NVAC with a better understanding of the costs associated with provision of vaccination services. These studies suggest that financial strains have affected vaccination practices among private and public providers and have the potential to affect future vaccine availability for patients.
To inform NVAC about current issues in vaccine financing, key stakeholders, including federal, state, and local governments, providers, consumers, vaccine manufacturers, health insurers, and employer groups, met with the Vaccine Financing Working Group in April 2008. Panels of stakeholder representatives gave informational presentations and provided feedback on proposed recommendations, including identification of preferred solutions to support child and adolescent vaccine delivery. This input, along with comments received during public review, was used to identify a consensus set of proposed recommendations addressing financial challenges to child and adolescent vaccination. The following recommendations, developed by NVAC, were presented at a public meeting of the full committee on September 16–17, 2008.2
Public-Sector Vaccine Purchasing for Underinsured Children and Adolescents
The Vaccines for Children (VFC) program should be extended to include access for VFC-eligible, underinsured children and adolescents receiving immunizations in public health department clinics and thus should not be limited to access only at federally qualified health centers and rural health clinics.
Funding Vaccine Administration Reimbursement for All VFC-Eligible Children and Adolescents
The VFC program should be expanded to cover vaccine administration reimbursement for all VFC-eligible children and adolescents. (Currently, the vaccine administration fee is not covered by the VFC program.) This should include children covered by Medicaid, because this would provide for a single system and uniform vaccine administration fee. The vaccine administration reimbursement should be sufficient to cover the costs of vaccine administration (as referenced elsewhere in these recommendations).
Recommendation 2 and recommendations 3 to 5 are designed to accomplish similar goals with respect to improving vaccine administration reimbursement in the VFC program. NVAC voted to approve both sets of recommendations with the understanding that the latter would not be needed if legislation were passed to cover administration fees for all VFC-eligible children through the VFC program, as in recommendation 2.
Improving Vaccine Administration Reimbursement for VFC-Eligible Children and Adolescents Enrolled in Medicaid
The Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) should annually update, publish, and disseminate actual Medicaid vaccine administration reimbursement rates according to state.
CMS should update the maximal allowable Medicaid administration reimbursement amounts for each state and should include all appropriate non–vaccine-related costs, as determined in current studies. These efforts should be coordinated with the American Medical Association review of relative value unit coding (recommendation 6).
The federal matching rate for vaccine administration reimbursement in Medicaid should be increased (ie, larger federal proportion) to levels for other services of public health importance (eg, family-planning services).
Supporting Vaccine Delivery in the Medical Home by Improving Business Practices in Private Provider Offices
The American Medical Association Relative Value Scale Update Committee should review its relative value unit coding to ensure that it reflects accurately the nonvaccine costs of vaccination, including the potential costs and savings with the use of combination vaccines.
Vaccine manufacturers and third-party vaccine distributors should work with providers on an individual basis to reduce the financial burden for initial and ongoing vaccine inventories, particularly for new vaccines. This might include extending payment periods (eg, from 60 days to 90 or >120 days, or until vaccine has been administered and reimbursed). It also might include options not related to payment terms for vaccine inventory.
Professional medical organizations should provide their members with technical assistance regarding efficient business practices associated with providing immunizations, such as how to contract and to bill appropriately. Medical organizations should identify best business practices to ensure efficient, appropriate use of Advisory Committee on Immunization Practices (ACIP)-recommended vaccines and appropriate use of Current Procedural Terminology codes, including evaluation and management codes, in claims for vaccines and vaccine administration. These organizations may receive federal assistance from CMS or other relevant agencies.
Medical providers, particularly in smaller practices, should participate in pools of vaccine purchasers to obtain volume ordering discounts. This might be accomplished through purchasing collaboratives formed by individual providers or through regional vaccine purchasing contracts held by professional medical organizations on behalf of providers.
Reducing Underinsurance Rates and Financial Barriers to Vaccination Through Voluntary Quality Standards for Health Insurance Plans
The CDC, professional medical organizations, and other relevant stakeholders should develop and support additional employer health education efforts. These efforts should communicate the value of good preventive care, including recommended vaccinations.
Health insurers and all private health care purchasers should adopt contract benefit language that is flexible enough to permit coverage and reimbursement for new or recently altered ACIP recommendations as well as vaccine price changes that occur in the middle of a contract period.
All public and private health insurance plans should voluntarily provide first-dollar coverage (ie, no deductibles or copayments) for all ACIP-recommended vaccines and their administration for children and adolescents.
Insurers and health care purchasers should develop reimbursement policies for vaccinations that are based on methodologically sound cost studies of efficient practices. These cost studies should factor in all costs associated with vaccine administration (including, for example, purchase of the vaccine, handling, storage, labor, patient or parent education, and record-keeping).
Activities of Federal Agencies and Offices Related to Financing of Vaccines for Children and Adolescents
Congress should request an annual report on the professional judgment of the CDC regarding the size and scope of the Section 317 program appropriation needed for vaccine purchase, vaccination infrastructure, and vaccine administration. Congress should ensure that Section 317 funding is provided at levels specified in the CDC annual report to Congress.
CDC and CMS should continue to collect and to publish data on the costs and reimbursements associated with public- and private-sector vaccine administration according to NVAC standards for vaccinating children and adolescents.3 These costs include those associated with the delivery of vaccines, such as purchase of the vaccine, handling, storage, labor, patient or parent education, and record-keeping. These published data should be updated every 5 years and should include information about reimbursement according to provider type, geographic region, and insurance status. State governments should use this information in determining vaccine administration reimbursement rates for Medicaid.
The National Vaccine Program Office should calculate the marginal increase in insurance premiums if insurance plans were to provide coverage for all vaccines routinely recommended by the ACIP.
The NVAC should convene ≥1 expert panel representing all affected stakeholders, to consider whether tax credits could be a tool to reduce or to eliminate underinsurance. The panel should determine whether policy options that would be acceptable to stakeholders could be developed to address the burden of financing for private-sector child and adolescent vaccinations by using tax credits as incentives for insurers, employers, and/or employees (consumers) and whether those credits would provide added value for vaccination of children and adolescents.
The CDC should substantially decrease the time from creation to official publication of ACIP recommendations, to expedite decisions by payers related to covering new vaccines and new indications for currently available vaccines.
Congress should expand Section 317 funding to support the additional national, state, and local public health infrastructure (eg, widespread, effective education and promotion for health care providers, adolescents, and parents; coordination of complementary and alternative venues for adolescent vaccinations; record-keeping and immunization information systems; vaccine safety surveillance; and disease surveillance) needed for adolescent vaccination programs, as well as child vaccination programs for new recommendations such as universal influenza vaccination.
Federal funding for cost/benefit studies of vaccinations targeted to children and adolescents should be continued.
Activities of State Agencies and Offices Related to Financing of Vaccines for Children and Adolescents
State, local, and federal governments and professional organizations should conduct outreach to physicians and nonphysician providers who serve VFC-eligible children and adolescents, to encourage those providers to participate in the VFC program if they currently do not. Outreach directed toward providers who serve adolescents and might not have provided vaccinations in the past (eg, obstetrician/gynecologists) is a particular priority.
States and localities should develop mechanisms for billing insured children and adolescents served in the public sector. The CDC should provide support to states and localities by disseminating best practices and providing technical assistance to develop these billing mechanisms (which may require additional resources not currently in the CDC immunization program budget). Furthermore, the NVAC urges states and localities to reinvest reimbursements from public and private payers in immunization programs.
Strategies to Support Child and Adolescent Vaccination in Complementary Venues
Adequate funding should be ensured to cover all costs (including those incurred by schools) arising from ensuring compliance with child and adolescent immunization requirements for school attendance.
Shared public/private-sector approaches to help fund school-based and other complementary-venue child and adolescent immunization efforts should be promoted.
STATUS AND NEXT STEPS
The NVAC approved these recommendations unanimously on September 16, 2008, and they have been forwarded to the Assistant Secretary for Health within the US Department of Health and Human Services for consideration. A fiscal analysis of the adopted recommendations has been prepared, and the NVAC will evaluate the extent to which its recommendations for financing child and adolescent vaccinations have been implemented by requesting a report detailing the implementation status of each recommendation 1 year after their formal adoption.
Members of the NVAC and its Vaccine Financing Working Group were as follows: NVAC: Guthrie S. Birkhead, MD, MPH (chair), New York State Department of Health; Jon R. Almquist, MD, Virginia Mason Medical Center; Richard D. Clover, MD, University of Louisville, Kentucky School of Public Health; Cornelia Dekker, MD, Stanford University School of Medicine; Mark Feinberg, MD, Merck; Jaime Fergie, MD, FAAP, Driscoll Children's Hospital; Lance K. Gordon, PhD, vaccine research and development consultant; Sharon G. Humiston, MD, MPH, Strong Memorial Hospital; Lisa A. Jackson, MD, MPH, University of Washington School of Public Health; Charles Lovell, Jr, MD, MACP, York Clinical Research; James O. Mason, MD, MPH, health care consultant; Marie McCormick, MD, ScD, Harvard Medical School; Christine Nevin-Woods, DO, MPH, Pueblo (Colorado) City-County Health Department; Trish Parnell, Parents of Kids with Infectious Diseases; Andrew Pavia, MD, University of Utah School of Medicine; Laura E. Riley, MD, Massachusetts General Hospital; Vaccine Financing Working Group of the NVAC: Guthrie S. Birkhead, MD, MPH (chair), New York State Department of Health; Jon S. Abramson, MD, Wake Forest University School of Medicine; Jon R. Almquist, MD, Virginia Mason Medical Center; Margaret S. Coleman, PhD, CDC, National Center for Immunization and Respiratory Diseases; Barbara Edwards, National Association of State Medicaid Directors; Mark Feinberg, MD, Merck; Gary L. Freed, MD, MPH, University of Michigan Health Systems; Bruce Gellin, MD, MPH, US Department of Health and Human Services, National Vaccine Program Office; Lance K. Gordon, PhD, vaccine research and development consultant; Elizabeth Greenbaum, MPH, National Business Group on Health; Anne C. Haddix, PhD, CDC, Office of the Director; Alan R. Hinman, MD, MPH, Task Force for Child Survival and Development; Calvin B. Johnson, MD, MPH, Pennsylvania Department of Health; Jeffrey Kelman, MD, CMS; Jerome O. Klein, MD, Boston University School of Medicine; Megan C. Lindley, MPH, CDC, National Center for Immunization and Respiratory Diseases; Walter A. Orenstein, MD, Emory University; Mark Pauly, PhD, University of Pennsylvania Wharton School; Amy A. Pisani, MS, Every Child by Two; Lance E. Rodewald, MD, CDC, National Center for Immunization and Respiratory Diseases; Alan Rosenberg, MD, WellPoint; Jenny Salesa, LLB, University of Michigan Health Systems; Angela K. Shen, MPH, US Department of Health and Human Services, National Vaccine Program Office; Gregory Wallace, MD, MS, MPH, CDC, National Center for Immunization and Respiratory Diseases; Joy Johnson Wilson, MRP, National Conference of State Legislatures; Anthony C. Wisniewski, JD, US Chamber of Commerce. Organizations represented at the NVAC Vaccine Financing Stakeholders Meeting, April 29–30, 2008, were as follows: 317 Coalition; Acambis; Aetna; Akorn; American Academy of Family Physicians; American Academy of Pediatrics; American Academy of Physician Assistants; American College of Obstetricians and Gynecologists; American Medical Association; American Pharmacists Association; America's Health Insurance Plans; Association of Immunization Managers; Association of State and Territorial Health Officials; Baxter Healthcare; Becton, Dickinson; Biotechnology Industry Organization; CDC; Connecticut Department of Public Health; CSL Biotherapies; Dalrymple & Associates; Dean & Co; Every Child by Two; George Washington University; GlaxoSmithKline; Health Industry Distributors Association; Henry Schein; Immunization Action Coalition; Infectious Diseases Society of America; Institute of Medicine; Louisiana State University Health Sciences Center-Shreveport; March of Dimes; Maxim Health Systems; McKesson Corp; MedImmune; Merck; National Association of County and City Health Officials; National Association of State Medicaid Directors; National Business Group on Health; National Conference of State Legislatures; NVAC; National Vaccine Program Office; New Hampshire Department of Health and Human Services; Novartis Vaccines and Diagnostics; Office of the Assistant Secretary for Planning and Evaluation; Office of the Assistant Secretary for Resources and Technology; Parents of Kids with Infectious Diseases; Pediatric Infectious Diseases Society; Pharmaceutical Research and Manufacturers of America; Rand; RPM Report; RTI International; sanofi pasteur; Task Force on Child Survival and Development; University of Colorado Health Sciences; University of Michigan Health System; University of Rochester; US Chamber of Commerce; US House of Representatives, Committee on Oversight and Government Relations; Virginia Department of Medical Assistance Services; WellPoint; World Vaccine Technologies; and Wyeth.
- Accepted August 25, 2009.
- Address correspondence to Megan C. Lindley, MPH, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mail Stop E-52, Atlanta, GA 30333. E-mail:
Some of the contributors are employees of the US Department of Health and Human Services. Although they served as contributors on the basis of their areas of expertise, the views expressed in this article are those of the National Vaccine Advisory Committee. The positions expressed and the recommendations made in this article do not necessarily represent those of the US government or of departmental employees who contributed.
Dr Orenstein's current affiliation is the Bill and Melinda Gates Foundation, Seattle, WA.
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
- ↵Lindley MC, Shen AK, Orenstein WA, Rodewald LE, Birkhead GS. Financing the delivery of vaccines to children and adolescents: challenges to the current system. Pediatrics.2009;124 (suppl 5):S548– S557
- ↵National Vaccine Program Office. National Vaccine Advisory Committee (NVAC) September 16–17, 2008, Meeting Minutes. Washington, DC: US Department of Health and Human Services; 2008. Available at: www.hhs.gov/nvpo/nvac/minutes200809.pdf. Accessed February 10, 2009
- ↵National Vaccine Advisory Committee. Standards for child and adolescent immunization practices. Pediatrics.2003;112 (4):958– 963
- Copyright © 2009 by the American Academy of Pediatrics