A summary of presentations from the weekly Summit partner webinars
May 18, 2023 – The latest Summit Summary
- Medicaid Adult Vaccine Provider Reimbursement: Physician Offices, Pharmacies, and FQHCs – Alessandra Fix and Mitchell Finkel (Avalere Health)
Medicaid Adult Vaccine Provider Reimbursement: Physician Offices, Pharmacies, and FQHCs – Alessandra Fix and Mitchell Finkel (Avalere Health)
Alessandra Fix, Associate Principal, Vaccine Policy and Mitchell Finkel, Consultant, Vaccine Policy and Market Access, Avalere Health, presented key findings from Avalere’s recently released white paper, Medicaid Adult Vaccine Provider Reimbursement in 2021: Comparison Across 50 States and Washington, DC.
- The Inflation Reduction Act (IRA) provisions being implemented in October will provide coverage for the cost of vaccines without patient co-pays, but this does not address the adequacy of payment for provider administration costs.
- In 2021 Avalere looked for gaps in the adult vaccine landscape by researching Medicaid adult vaccine reimbursement policies for physician offices, pharmacies, and FQHCs.
- The research utilized publicly available resources (e.g., fee schedules, provider and/or patient manuals, coverage policies, and preferred drug list [PDLs]) to examine fee for services (FFF) reimbursement for administration of Tdap, PCV13, PPSV23, and HPV in all 50 states and DC.
Results: Physician Offices
- Medicaid reimbursement for vaccination services quite variable; some combination of vaccine product used and previously established vaccine administration fees.
- No established definition for “adequate” payment to cover the physician’s expenses, although AAP recommends this be at least 125% of private sector price.
- Most common standard for setting a rate is based on what Medicare Part B reimburses.
- Most (80%) of states reimburse below the Medicare payment rate.
- State Medicaid programs can impose restrictions on whether pharmacies eligible to receive reimbursement for vaccine administration.
- Study focused on whether a state allowed pharmacy to receive reimbursement; did not include scope of practice policies.
- 22 states + DC permit pharmacy reimbursement for all studied vaccines.
- Half of states did not permit reimbursement for at least one of the studied vaccines, with 10 of these not reimbursing for any of these vaccines.
Results: Federally Qualified Health Centers (FQHCs)
- FQHC reimbursement most complex of the 3 provider types studied.
- 50% of FQHC patients are Medicaid eligible
- Most FQHCs reimburse for immunizations as part of predetermined per-visit payment rate using PPS (prospective payment system) or APM (alternative payment methodology)
- Majority of states do not allow vaccine reimbursement outside of encounter, i.e., not for an “immunization only” visit; generally considered to be included in PPS rate, though some states provide reimbursement as “incidental to” other services if provided by a “billable provider” (often doesn’t include nurses).
- 12 states have an alternative pathway to ensure FQHCs are reimbursed for vaccination services without regard to the type of visit or provider
Potential reimbursement-related reforms (not exhaustive list)
- Creating federal standards for Medicaid provider reimbursement rates for both products and their administration
- Establishing Medicaid coverage and reimbursement parity among all provider types vaccinating adults
- Establishing payment reforms to ensure FQHCs are incentivized to vaccinate Medicaid beneficiaries
Q: How does the HHS $350 million to FQHCs for COVID vaccine apply?
Mitchell Finkel: I think this $350 million might have been allocated last year, but there could have been more funding since. At the time, I believe that was going toward COVID-19 vaccination clinics and supporting FQHCs in assuring they have the operating capabilities to administer COVID-19 vaccines. So that $350 million is independent of this discussion, especially since COVID-19 vaccines are not yet purchased and reimbursed by the system. This predominately affects those that are being administered through the coverage and access system. I will say that FQHCs are this key safety net provider we always talk about, and they are one of those eligible entities that receive Section 317 funding for the vaccines they administer, so, to the extent that an FQHC sees an uninsured patient, they may be receiving a state-provided dose through a Section 317 program. So that’s where some federal funding for vaccines also flows through an FQHC. I will have to double-check on whether that funding is still available to an FQHC or not.
Q: Could you please repeat the proportion of states who use Medicare level payments for vaccines and vaccine administration?
Mitchell Finkel: I would say it depends on whether we’re talking about vaccine products or vaccine administration. I don’t think there’s a consistent usage of Medicare for all financing of the program. But when we looked at vaccine administration, which is the one that we most commonly think of – so the actual service of administering a vaccine – we saw that at the time, and I believe the standard of the paper was that 85% of states were reimbursing below the Medicare rate for vaccine administration. If you use the now $30 rate, it would be almost all states. And then for vaccine products, the Medicare payment depends on the vaccine. For example, PPSV23 and PVC13 were more commonly reimbursed at the Medicare rate, but it was not consistent, and many states still reimbursed below that rate.
Alessandra Fix: Also, states establish payment rates by updating their fee schedules. There are different processes by state, so that it could be that a state updated their payment rate a few years ago for a product and hasn’t updated it in a couple of years, so it could be a couple of dollars below. So, there could be a timing issue or a process issue, even if states were benchmarking to the Medicare payment at some point – is that still up to date? And to the other part of your question as to how well vaccine payments for adults compare to vaccine payments for children – children look a little bit different in the Medicaid department, given the Vaccines for Children (VFC) Program where the federal government is purchasing the doses and then they are being distributed. So, providers aren’t buying and billing the same way that they are for adult vaccines.
L.J Tan: One of the things we do know is that the VFC administration fee comes out of the state Medicaid program, and, as with the adult program, varies from state to state. Some states are tremendously low, and other states are closer to adequate levels – from $15–$20 for administration. But it does vary from state to state at the VFC level.
Mitchell Finkell: Even within states we see a different reimbursement rate for a child visit versus an adult visit. So, there is uneven parity even within a state.
Alessandra Fix: A future paper could look at some of the variability for administration with a VFC dose.
L.J Tan: As an FYI, the Adult Vaccine Access Coalition (AVAC) is looking at adequacy of provider payment at both the Medicare and Medicaid levels. They have formed subgroups to try to work through some of the policy questions, and they are complicated. There are a lot of challenges even within Medicare itself, and that’s certainly thought of as the easier level because it’s federal. If you’re interested in joining the work that’s being done by AVAC, drop me an email at firstname.lastname@example.org, and I will be sure to connect you with AVAC so that you can participate with the AVAC work. Or you can directly email Katie Pischke at AVAC; let her know that you heard about their work on a weekly Summit call.
Q: Have you had discussions with state and local policymakers that have successfully improved payments so that it’s not cost-prohibitive to providers? Are there any messages that seem to resonate with legislators or other regulators to help make it affordable for providers to offer vaccine?
Mitchell Finkell: I think it’s a good point that, while we all want to increase vaccine administration reimbursement rates, it does cost funds to do so. And states have to adjust their budgets to look at the value. I think one of those key messages that we always come back to is that vaccines are cost-saving. They prevent diseases in the future that would cost the Medicaid program additional funds to take care of recipients. Coming back to the value of vaccines is the key message we see working and resonating with people. You could see this year that New York had put in their budget to increase the childhood vaccine administration rate. So, using that message for adults in addition to children could be a starting point.
Alessandra Fix: I completely agree that’s one of the strongest messages. I will say our job at Avalere is not to go to states and have those conversations with state policymakers – it’s to equip you with data that can be helpful in identifying what are the states to target or helping communicate those messages. I think as Mitchell mentioned talking about the value of vaccines in reducing spending over the long run is one that can particularly resonate with states. The other thing I would say is that we’ve talked about the IRA and there are several states that will be making changes to coverage policies for vaccines to comply with the IRA in October, so now could be an opportune time to engage those states that are making changes anyway or kind of looking across their coverage or co-pay policies. So, this is a good time to start having those conversations at the state level because there’s some momentum here, and we should take advantage of that.
Carolyn Bridges: We certainly heard at the (in-person) Summit many concerns from providers across the whole range of people that provide immunizations that inadequate payment is causing significant issues. Be looking for more information from the Summit about how we might be able to assist somewhat.
L.J Tan: A reminder that this is a fairly complicated issue; a push on one side ends up being a pull on the other side. If you improve payment to commercial private sector physicians, you have to be very careful not to create a solution that ends up impacting the ability of pharmacies, for example, to bill on the other side. So, it’s a very complicated push and pull system. Please get involved – I think the AVAC working groups are a great place to get started on the policy changes.
Q: Is there any similar parallel situations that you can point to besides vaccines where they have solved this problem – where you have a service delivered or a medication that is part of the total payment that somehow has been carved out? Is there something we could point to as a model for how we could solve this problem related to vaccines, or is our situation unique?
Mitchell Finkel: That’s a really good question, and I think it depends on the provider type. So, to your point on “carving out,” which is in reference to the FQHCs, we have seen states carve out long-acting reversible contraceptive (LARC) reimbursements pretty consistently, because it was not financially profitable for FQHCs to provide long-acting contraception, and they took action to resolve that barrier. I think that’s the best example in the FQHC front. For the other areas, there’s been an ongoing discussion about the level of reimbursement for primary care in Medicaid. There is a recent rule form CMS trying to get at ensuring primary care is sufficient, but it’s in the early stages, and we’re still looking to see the implementation of that. So there’s still more to be seen as it relates to how to increase reimbursement for physician offices. Unfortunately, I think pharmacy vaccination might be the unique example because this is one of the only services that are routinely covered by Medicaid.
Alessandra Fix: I just want to emphasize that the long-acting reversible contraceptive example is a good parallel. There are some interesting papers and some data demonstrating the impact of carving it out on access that you could turn to. We’ll give some thought to whether there are other good examples, but I would encourage folks to take a look at that.
Kelly Moore: Thank you very much. That’s helpful at least with one of the challenges. If we have a situation that we can look to that is parallel, it gives us a pathway to consider. At least we can start somewhere.
Q: A suggestion for future work – an examination of Medicaid VFC reimbursement rates in pharmacies.
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