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Position paper of the Society for Adolescent Health and Medicine| Volume 48, ISSUE 3, P320-321, March 2011

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Financing Vaccines for Adolescents: A Position Paper of the Society for Adolescent Health and Medicine

      Abstract

      An increasing number of vaccines are now recommended for adolescents. These vaccines may greatly improve the health of adolescents and their communities. However, adolescent vaccine coverage rates lag behind those for infants and behind goals set by Healthy People 2010 [
      National, state, and local area vaccination coverage among adolescents aged 13–17 years—United States, 2009.
      ]. Financial constraints have been reported to be a significant obstacle to immunizing adolescents and young adults [
      • Ford C.A.
      • English A.
      • Davenport A.F.
      • Stinnett A.J.
      Increasing adolescent vaccination: Barriers and strategies in the context of policy, legal, and financial issues.
      ]. At the Society for Adolescent Health and Medicine, we believe that to achieve increased vaccine coverage in this age group, financial barriers to immunization must be removed.
      The Society for Adolescent Health and Medicine (SAHM) supports the following positions:
      • 1
        Financial barriers for adolescents and young adults to receive routinely recommended vaccines should be eliminated. Strategies supported by SAHM to help achieve this goal include:
        • Mandating private insurance coverage for all Advisory Committee on Immunization Practices recommended vaccines;
        • Expansion of the Vaccines for Children (VFC) program to cover all eligible individuals up to 26 years of age;
        • Expansion of safety net funding to subsidize vaccine costs for adolescents and young adults who are underinsured.
      • 2
        All providers serving adolescents, including nontraditional providers, should be able to immunize without financial risk. Strategies supported by SAHM to achieve this goal include:
        • Elimination of inequities in vaccine purchase prices and third-party reimbursement faced by private practitioners;
        • Use of purchasing collectives to allow individual, small group, and nontraditional providers such as family planning clinics, juvenile detention centers, or schools access to vaccines at fair market costs;
        • Provision of standard administrative fees by all insurance plans, both government and private, sufficient to cover all expenses associated with vaccine storage and delivery;
        • Participation in the VFC program by all providers serving adolescents, including nontraditional providers such as family planning clinics, juvenile detention centers, or schools.
      • 3
        The use of immunization information systems by all providers delivering vaccines to adolescents and young adults to reduce both resource duplication and missed opportunities for vaccination.

      Background

      In the past several years, the number of recommended vaccines for adolescents has grown substantially [
      CDC
      Recommended immunization schedules for persons aged 0 through 18 years—United States, 2010.
      ]. These vaccines have the potential to improve the health of our youth by preventing meningitis, pertussis, influenza, cervical cancer, and its dysplastic precursors. Furthermore, by immunizing adolescents, we are likely to reduce the spread of diseases in communities. An additional benefit of new recommendations to immunize adolescents is that they are likely to lead to increased office visits and thus present an opportunity to provide teenagers with other recommended preventive health services [
      • Broder K.R.
      • Cohn A.C.
      • Schwartz B.
      • et al.
      Adolescent immunizations and other clinical preventive services: A needle and a hook?.
      ,
      • Rupp R.
      • Rosenthal S.L.
      • Middleman A.B.
      Vaccination: An opportunity to enhance early adolescent preventative services.
      ].
      However, each new vaccine for this age group brings additional costs to an economically fragile and fragmented healthcare system [
      • Lee G.M.
      • Lieu T.A.
      Vaccine financing in the United States: An emerging crisis.
      ]. Current private sector costs of the newly approved adolescent vaccines range from $37.55 for the pertussis booster, and $103.41 for the meningitis vaccine, to $390.81 for the three-dose human papillomavirus vaccine. This can be an insurmountable barrier for adolescents required to pay out-of-pocket for these vaccines. In the past, state and section 317 funds were used as a safety net, to assist in making vaccines available at reduced or no cost. However, with the rising cost of newer vaccines, these funds are insufficient. In recent years, those most likely to face financial barriers to immunization have included young adults aged ≥19 years who face high rates of being uninsured [
      • Callahan S.T.
      • Cooper W.O.
      Uninsurance and health care access among young adults in the United States.
      ] and do not qualify to receive free vaccines through the federal VFC program, and teenagers aged ≤18 years who are underinsured. Underinsured adolescents are those who are privately insured but whose insurance does not cover all the costs of currently recommended vaccines. According to a recent analysis, more than 30% of adolescents may be underinsured for immunizations [
      • Smith P.J.
      • Lindley M.C.
      • Shefer A.
      • Rodewald L.E.
      Underinsurance and adolescent immunization delivery in the United States.
      ]. Although the healthcare reform bills of 2010 are likely to increase insurance coverage among young adults, vaccine financing for this age group is not guaranteed. Further efforts are needed to ensure that young adults can access vaccines without financial barriers.
      The current U.S. system for vaccine financing is challenging for providers as well as for patients. Maintaining vaccines in an office setting requires a significant upfront investment to purchase vaccines. Substantial staff time is also needed to oversee vaccine storage, handling, and to monitor inventory and waste of expired product. Providers report wide variations in private vaccine purchase prices and third-party reimbursements [
      • Freed G.L.
      • Cowan A.E.
      • Gregory S.
      • Clark S.J.
      Variation in provider vaccine purchase prices and payer reimbursement.
      ]. Some providers are immunizing patients at a financial loss to their practice and are considering suspending this service [
      • Freed G.L.
      • Cowan A.E.
      • Clark S.J.
      Primary care physician perspectives on reimbursement for childhood immunizations.
      ]. For vaccines administered through the VFC program, providers receive vaccines at no cost but administrative fees may not be adequate to cover overhead expenses. In addition, administrative fees for publicly administered vaccines can vary widely.
      Vaccine financing for adolescents and young adults is further complicated by the varied patterns of healthcare use in this age group. Adolescents are less likely than younger children to present for routine preventive health visits [
      • Rand C.M.
      • Shone L.P.
      • Albertin C.
      • et al.
      National health care visit patterns of adolescents: Implications for delivery of new adolescent vaccines.
      ,
      • Irwin Jr, C.E.
      • Adams S.H.
      • Park M.J.
      • Newacheck P.W.
      Preventive care for adolescents: Few get visits and fewer get services.
      ]. They often receive medical services from nontraditional providers, such as family planning clinics, juvenile detention centers, or schools. Vaccines may not be offered at these sites because of financial constraints. Immunization registries may be important for facilitating immunization of adolescents outside of the medical home, reducing record scattering, and preventing over-immunization (repeated vaccination because of missing vaccine records). However, to date adolescents are less likely than younger children to have their immunizations reported to an immunization registry [
      Progress in immunization information systems—United States, 2008.
      ].
      SAHM values the individual and public health benefits of immunizations and encourages healthcare delivery systems that allow adolescents and young adults to receive all recommended vaccines at sites where they currently receive other medical services. Although recent recommendations by the National Vaccine Advisory Committee to expand public financing for immunizations are to be applauded [
      National Vaccine Advisory Committee
      Financing vaccination of children and adolescents: National Vaccine Advisory Committee recommendations.
      ], further actions are needed to reduce financial barriers to immunization for adolescents and young adults.

      References

      1. National, state, and local area vaccination coverage among adolescents aged 13–17 years—United States, 2009.
        MMWR Morb Mortal Wkly Rep. 2010; 59: 1018-1023
        • Ford C.A.
        • English A.
        • Davenport A.F.
        • Stinnett A.J.
        Increasing adolescent vaccination: Barriers and strategies in the context of policy, legal, and financial issues.
        J Adolesc Health. 2009; 44: 568-574
        • CDC
        Recommended immunization schedules for persons aged 0 through 18 years—United States, 2010.
        MMWR CDC Surveill Summ. 2010; 58: 1-4
        • Broder K.R.
        • Cohn A.C.
        • Schwartz B.
        • et al.
        Adolescent immunizations and other clinical preventive services: A needle and a hook?.
        Pediatrics. 2008; 121: S25-S34
        • Rupp R.
        • Rosenthal S.L.
        • Middleman A.B.
        Vaccination: An opportunity to enhance early adolescent preventative services.
        J Adolesc Health. 2006; 39: 461-464
        • Lee G.M.
        • Lieu T.A.
        Vaccine financing in the United States: An emerging crisis.
        Arch Pediatr Adolesc Med. 2009; 163: 485-487
        • Callahan S.T.
        • Cooper W.O.
        Uninsurance and health care access among young adults in the United States.
        Pediatrics. 2005; 116: 88-95
        • Smith P.J.
        • Lindley M.C.
        • Shefer A.
        • Rodewald L.E.
        Underinsurance and adolescent immunization delivery in the United States.
        Pediatrics. 2009; 124: S515-S521
        • Freed G.L.
        • Cowan A.E.
        • Gregory S.
        • Clark S.J.
        Variation in provider vaccine purchase prices and payer reimbursement.
        Pediatrics. 2009; 124: S459-S465
        • Freed G.L.
        • Cowan A.E.
        • Clark S.J.
        Primary care physician perspectives on reimbursement for childhood immunizations.
        Pediatrics. 2009; 124: S466-S471
        • Rand C.M.
        • Shone L.P.
        • Albertin C.
        • et al.
        National health care visit patterns of adolescents: Implications for delivery of new adolescent vaccines.
        Arch Pediatr Adolesc Med. 2007; 161: 252-259
        • Irwin Jr, C.E.
        • Adams S.H.
        • Park M.J.
        • Newacheck P.W.
        Preventive care for adolescents: Few get visits and fewer get services.
        Pediatrics. 2009; 123: e565-e572
      2. Progress in immunization information systems—United States, 2008.
        MMWR Morb Mortal Wkly Rep. 2010; 59: 133-135
        • National Vaccine Advisory Committee
        Financing vaccination of children and adolescents: National Vaccine Advisory Committee recommendations.
        Pediatrics. 2009; 124: S558-S562