Insurers Take up Mantle to Ensure Immunizations

MHE PublicationMHE November 2020
Volume 30
Issue 11

Health plans build strategies to ensure their beneficiaries have easy access to and receive vital immunizations.

Although resistance to vaccination hasn’t a major challenge for health plans, they are not sitting back and letting preventive care fall through the cracks. Instead, many insurers have strategies for promoting vaccination — against a variety of childhood diseases, the flu and COVID-19, once a vaccine becomes available — and are encouraging providers to dispense them and ensure patients are receiving them.

That’s not to say that anti-vaccination sentiment doesn’t exist. California State Sen. Richard Pan, a pediatrician, says he has been a victim of such opinions by some who use ratings sites to downgrade providers and file complaints with their employers. He introduced legislation, which was signed into law last year, that requires health officials to approve requests for medical exemptions to school-required vaccinations and grants officials the authority to revoke medical exemptions if they are found to be fraudulent or inconsistent with state guidelines. The law red-flags any provider who issues more than five vaccine exemptions a year and schools that fall below a 95% immunization rate.

“We are on top of the flu vaccination because a healthcare system can ill afford to let additional patients get sick and have to visit the ER,” says Steve Miller, M.D., chief clinical officer for Cigna. “In addition, paying attention allows us to develop a vaccination infrastructure for COVID-19, which will be different because patients can’t stand in line and wait for a vaccination. A plan also helps establish trust in the healthcare system.

“A flu shot is usually pretty straightforward but atypical today; there is no employer-sponsored campaign when employees are working at home so we need a broader provider network to ensure vaccinations are more readily available,” Miller says. Childhood vaccinations and preventive care, in general, are down as fewer people are getting routine checkups and screenings because of COVID-19, he says.

Jaja Okigwe, MBA, president and CEO of First Choice Health, a healthcare benefits administrator based in Seattle, says the root of barriers to vaccines is reluctance of beneficiaries to visit a doctor because off the pandemic. Fifty-one percent of U.S. adults now say they would definitely or probably get a vaccine to prevent COVID-19 if it were available , according to the Pew Research Center. That is a significant drop from May, when 72% indicated they would be willing to get vaccinated.

Partly because immunization rates are part of the Healthcare Effectiveness Data and Information Set (HEDIS) measures, health plans and providers have an incentive to keep immunization rates high.

Cigna has created three pilot programs to manage the flu vaccination for underserved populations in Houston, Memphis, Tennessee, and South Florida. The program provides participants with personal protective equipment kits that include masks and sanitizers, connects them with primary care physicians, and provides bus transportation. The response has been positive.

The pilots also use spokespeople whom members trust, such as local sports stars, clergy, and political leaders, to get the message across to get a flu shot. “There are many social influencers besides doctors that will resonate with members and build confidence,” Miller says. “This has been a true campaign, not just a one-time thing. It’s time to break the code of serving these populations and positively impact these communities.”

Cigna also encourages its providers to build trusted relationships with patients and send a message to get a flu shot.

Creating vaccine strategies

Kristine Grow, senior vice president of communications for America’s Health Insurance Plans, says insurers have an essential role to play as vaccines are approved, in pricing and distribution models, vaccine administration, coverage (they will be covered like other vaccines), and payment and post-market monitoring. They are preparing to:

  • Follow prioritization recommendations and weigh in if needed to make recommendations.
  • Leverage claims data in advance to identify members who meet the criteria to receive the vaccine and remind them to get the appropriate doses in the right time frames.
  • Collaborate with national, state, and local stakeholders to get the vaccines to the public.
  • Help educate Americans on safety and effectiveness of a COVID-19 vaccine.

“Our role is to pay for vaccinations and for our providers to dispense them,” says Bob Freeman, CEO of CenCal Health, a Medicaid plan that covers 186,000 people in Santa Barbara and San Luis Obispo counties in California.

“Our emphasis is on how to make easier to get vaccinations and what vehicle to use to communicate most effectively,” Freeman says. “Resistance is not a big problem in the Medicaid population; most are hungry to get vaccinations.”

CenCal has developed a comprehensive program educating and notifying members about obtaining preventive and primary care.

It includes:

  • Mailers sent to parents and caregivers of infants and children up to 6 years old who have not received a checkup or well check within the past six months.
  • CenCal Health’s member newsletter sent to all member households with age-specific preventive health guidelines for adults and children; education for parents about the importance of pediatric well visits; and assurances of safe visits.
  • Website with content focused on what provider offices are doing to prevent spreading COVID-19 to well patients and encouraging parents to call their primary care provider about specifics.
  • Media campaigns — television, radio, newspaper, and social media — in English and Spanish featuring recognized local physicians and clinics explaining their safety measures, such as drive-through vaccine clinics for children.

Despite resistance being at a low level, Freeman says the importance of vaccinations should be reinforced. CenCal does not yet have messaging for COVID-19 because “we don’t want to get ahead of the public health department whose direction we follow,” Freeman says.

Texas Children’s Health Plan, a Medicaid health plan in the Houston area, ensures children and women have broad access to vaccines as an integral part of its mission. “We know vaccines are critical in preventing the spread of diseases, which is why we encourage our members to stay up to date on their vaccine schedule and to get a flu vaccine each year,” says Anna Mateja, the health plan’s vice president.

“As a Medicaid managed care organization, we will adhere to the guidelines set forth by state and federal health authorities regarding a COVID-19 vaccine when that becomes available, as we do with the flu vaccine and others,” Mateja says.

PBMs play role

Prime Therapeutics, a PBM based in Minnesota’s Twin Cities metro area, is using efficacy and safety data to study each COVID-19 vaccine option and will rely on the FDA’s labeling to ensure the vaccines are being provided to members in an appropriate manner.

David Lassen, chief clinical officer, says Prime will place COVID-19 vaccines on its national formulary as it does for all vaccinations recommended by CDC, whose guidance the PBM follows. He doesn’t anticipate prior authorization or other utilization management programs for COVID-19 vaccines.

“Our goal will be to ensure the shortest turnaround time from product launch to claim adjudication and administration to our members,” Lassen says. “We will be working with our health plans to encourage members to get the vaccine just as they would any flu vaccine, as both are important protections for the health of the member as well as the community.”

He sees the entire pharmacy supply chain working together to ensure beneficiaries receive a COVID-19 vaccine. Insurers would ensure access to the pharmacy benefit and coverage and pharmacy networks would distribute the vaccines. “Everyone is stepping up so we can be ready to serve the public when the vaccines are available,” Lassen says.

Mari Edlin is a healthcare writer in Sonoma, California.

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