Medicare and Medicaid Responses to Pneumococcal Vaccines


Cost considerations for the rollout of new pneumococcal vaccines are discussed by a panel of medical experts.

Ryan Haumschild, PharmD, MS, MBA:Setting up for success comes from providers but also our largest payers. Dr Schaffner, how has the Centers for Medicare & Medicaid Services [CMS] responded to make sure we have access to the newer pneumococcal and other vaccines that have entered the market?

William Schaffner, MD: It’s my understanding that pneumococcal vaccines, even newer formulations, because they’re recommended for adults and individuals ages 65 and older, will be covered under Part B, first-dollar coverage. You just have to roll up your sleeve. You don’t have to reach for your wallet. That’s great. For individuals under age 65, we revert to our conventional public-private system of providing medical care. We have to be attentive to that because there will be individuals in the gaps who don’t have medical insurance. But we need to do everything we can to reach out to them and make sure they have vaccines available.

Ryan Haumschild, PharmD, MS, MBA: I completely agree. Getting CMS to recognize that reducing the barriers to making sure they can get the latest vaccines is important. Even for those who are at risk and aren’t covered within CMS, how do we create that halo effect for a lot of our commercial plans? Dr Madison, I’ll bring this question back to you. What are the benefits of CMS making sure we have access to these newer pneumococcal vaccinations? How can we encourage our commercial payer colleagues to adopt that same approach?

Christina Madison, PharmD, FCCP, AAHIVP: I want to go back to the original comment about the vaccination neighborhood, which I love. I totally want a T-shirt that says, “The footnotes are your friend in the vaccination and immunization neighborhood.” I’m going to do that after this. When I think about our ability to impact change and move the needle, [we need to] start with being able to pay for these vaccines for our seniors, looking at the benefits from not just a health benefit and public health standpoint but also a pharmacoeconomic standpoint. When we think about the number of hospitalizations avoided from a payer standpoint, I’d much rather pay for a vaccination vs a hospitalization. Looking at that model for the geriatrics population and the Medicare population, it will eventually trickle down. We see this being done specifically through federal legislation, with the implementation of the Inflation Reduction Act last year. That has a specific vaccine component in addition to the capping of insulin prices and overall prices of co-pays. Hopefully the private sector will be influenced by the public sector as we move forward with the reasons why prevention is going to help with overall health care costs.

Ryan Haumschild, PharmD, MS, MBA: I agree: follow CMS’s lead, be good stewards of the health care dollars of these employers, do the pharmacoeconomic analysis, and recognize that early intervention and utilizing the latest vaccinations can improve the lives of our patients. We have enough barriers to vaccination hesitancy and the lack of education. Let’s not make our payer coverage 1 of those.

Christina Madison, PharmD, FCCP, AAHIVP: Looking at the federal side, in addition to the VFC [Vaccines for Children] program and the [Section] 317 program, which is specific to uninsured and underinsured adults, they’re rolling out an adult vaccination program that’s modeled after VFC. Hopefully that will come out soon, and we’ll have the cost of the vaccine at a minimum covered, with just the administration cost accrued by the patient. If they went to a health department, an FQHC [Federally Qualified Health Center], Indian Health Services, or Indigenous Services [Canada], they would have no fees associated with vaccination.

Ryan Haumschild, PharmD, MS, MBA: Excellent. Thank you to this expert panel for a robust discussion about pneumococcal vaccines. To our viewing audience, we hope you found this Pharmacy Times®Peer Exchange to be rich and informative.

Transcript edited for clarity.

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