ATLANTA — The shingles vaccine is now officially recommended for all adults aged 60 and older, but getting it paid for under Medicare could represent a barrier for patients and physicians.
At its fall meeting, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention voted to recommend Merck's live attenuated zoster vaccine (Zostavax) for routine administration in adults aged 60 years and older. The committee did not recommend routine use of the vaccine in adults younger than 60 (Merck has applied for, but not yet received, licensure of the vaccine for adults aged 50–59), nor in adults who are or will become immunocompromised. The decision to use the vaccine in these individuals was left to the physician's judgment. The vaccine may be given whether or not the patient had a previous episode of shingles.
The American Academy of Family Physicians will also endorse the vaccine, said Dr. Jonathan L. Temte, the AAFP's liaison to the ACIP, who has written the recommendations for approval by the AAFP's Commission on Science. “Family physicians are very aware of zoster and postherpetic neuralgia [PHN]. … I'm very positive about this vaccine, but I'm concerned about the bill,” he said in an interview.
Indeed, there is broad concern about payment for this and other new adult vaccines under Medicare. At the ACIP meeting, Dr. Jeffrey A. Kelman, chief medical officer at the Center for Beneficiary Choices of the Centers for Medicare and Medicaid Services, outlined the current situation.
Under Medicare Part B, vaccine costs and administration fees are covered for just three vaccines: influenza, pneumococcal disease, and hepatitis B. Other preventive vaccines that are licensed for adults and considered medically necessary, such as diphtheria-tetanus and Zostavax, fall under the new Part D, which is administered by individual drug plans that contract with pharmacies. The pharmacies bill the plan directly and charge the beneficiary appropriate copays.
Part D copays vary across plans, but a typical middle-class beneficiary will pay about 25% of the cost. Lower-income beneficiaries, including so-called “dual eligibles” who also qualify for coverage under Medicaid, will have standard copays between $1 and $5, depending on income level.
Because Part D is a drug benefit administered through pharmacies, it is not designed to reimburse for medications provided in a physician's office, nor does it cover administration fees. Physicians can bill a patient's secondary insurance or Medicaid for the administration fee. These amounts vary, but $18 is the current fee for influenza vaccination. For patients who do not have coverage under either of those options, the only choices are to bill the patient for the fee or swallow the cost.
Dr. Temte believes that most physicians will end up doing the former. “I anticipate an abundance of calls from patients asking why they are being charged,” he said.
As for coverage for the cost of vaccine itself—about $150—Dr. Kelman noted that Part D does provide payment that was not available prior to the implementation of Part D in January 2006. “It's a significant benefit. Everybody should end up better this year than last.”
Medicare has developed a set of options to improve access to vaccines under Part D that would minimize the burden of up-front payments and paperwork filing by the patient. “Zostavax is the test case,” he said.
One “in-network” approach would have the Part D plan's specialty pharmacy provide vaccines directly to the physician's office. The physician would call in a prescription, and the pharmacy would ship the vaccine to the physician's office and bill the Part D plan.
Another in-network option would involve patients' obtaining a prescription for the vaccine from the physician and bringing it to their local network retail pharmacy for filling. In 44 states, pharmacists are allowed to administer vaccines. Included in this approach are specialty pharmacies located in nursing homes and long-term care facilities, and home infusion companies, most of which are in-network providers, Dr. Kelman noted.
The “out of network” category includes other options for facilitating payment for patients to receive Zostavax in the physician's office. In one scenario, a Part D plan would provide its enrollees with a vaccine-specific notice that they would bring to their physicians. The physician would contact the plan for authorization, bill the plan using a standard paper or electronic form, and receive payment from the plan. Alternatively, a commercially developed Web-based system would let physicians electronically bill Part D plans for vaccines dispensed and administered in the office. The physician would either enter into a contract with the plan to be a nonpharmacy network provider, or would agree to accept Part D payment as a condition for using the system. “We expect all of these routes to be used,” Dr. Kelman said.
The Web-based option is preferred by vaccine manufacturers and professional societies. In a June 29 letter to CMS, 13 medical groups, including the AAFP, the American Medical Association, the American College of Physicians, and the American Academy of Neurology, said: “In addition to ensuring that administration of [zoster vaccine] is payable by Medicare, it is also important to develop a mechanism for Medicare prescription drug plans to pay the cost of the vaccine itself through Medicare Part D without imposing new paperwork burdens on physicians or impeding patients' access to the new vaccine. Of the four options … only the last one, Web-assisted electronic billing, meets these objectives.”
The letter also pointed out that Zostavax has been shown to be cost effective, given that treating a case of herpes zoster costs $437–$805 in the first 3 months, while the subsequent cost for those who develop postherpetic neuralgia is about $1,727. (Data suggest that the vaccine can prevent PHN; the vaccine is not licensed for that indication.)
In Dr. Temte's view, “I think family physicians will order it and make it available, especially with the ACIP recommendation and AAFP's endorsement, but the [current payment situation] brings into question the overall wisdom of lack of coverage for preventive services through Medicare.”
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