The COVID-19 Uninsured Program: Nearly 39 Million Vaccine Doses Were Funded, 2020-22.

The COVID-19 Uninsured Program, administered by the Health Resources and Services Administration (HRSA), reimbursed providers for administering COVID-19 vaccines to uninsured US adults from December 11, 2020, through April 5, 2022. Using HRSA claims data covering forty-two states, we estimated that the program funded about 38.9 million COVID-19 vaccine doses, accounting for 5.7 percent of total doses distributed and 10.9 percent of doses administered to adults ages 19-64.

Direct Medical Costs Associated With Post-COVID-19 Conditions Among Privately Insured Children and Adults.

INTRODUCTION: SARS-CoV-2, the virus that causes COVID-19, has caused more than 100.2 million infections and more than 1 million deaths in the US as of November 2022, yet information on the economic burden associated with post-COVID-19 conditions is lacking. We estimated the possible economic burden associated with post-COVID-19 conditions by comparing direct medical costs among patients younger than 65 years with and without COVID-19 in the postacute period. METHODS: Commercially insured children and adults with a COVID-19 diagnosis (cases) during April-August 2020 were matched to those without COVID-19 (controls) on a 1:4 ratio. Direct medical costs represented 1-, 3-, and 6-month total expenditures per person starting 31 days after the diagnosis date. We used a 2-part model to evaluate cost differences among individuals with and without COVID-19, adjusted for patient characteristics. RESULTS: Costs were higher among cases compared with controls. Direct medical costs among child cases were 1.82, 1.72, and 1.70 times higher than controls over 1, 3, and 6 months, respectively. Direct medical costs among adult cases were 1.69, 1.54, and 1.46 times higher than costs among controls over 1, 3, and 6 months, respectively. Relative differences in costs were highest among adults aged 50 to 64 years. In a subset of people with COVID-19, costs were higher among hospitalized cases compared with nonhospitalized cases. CONCLUSION: Our findings suggest a considerable economic burden of COVID-19 even after the resolution of acute illness, highlighting the importance of prevention and mitigation measures to reduce the economic impact of COVID-19 on the US health care system.

Increasing equity in adult immunization through community-level action.

Inequities in availability and access to adult vaccinations represent significant gaps in the US public health infrastructure. Adults in racial and ethnic minority groups are less likely to receive routinely recommended vaccinations due to systemic barriers, distribution inequities, and lack of trust in vaccines; similar disparities were seen during early COVID-19 vaccination efforts. However, a deliberate focus on reducing disparities can yield progress. National data show narrowing of racial and ethnic adult COVID-19 vaccination coverage disparities over time, highlighting the value of the equity-focused, community-level interventions implemented during the pandemic. This paper describes the Centers for Disease Control and Prevention's efforts during the COVID-19 pandemic to address racial and ethnic disparities in adult immunization, and how lessons learned may be applied post-pandemic. Progress made is likely to be lost without sustained support for adult vaccination at national, state, and community levels.

Racial and Ethnic Disparities in Adult Vaccination: A Review of the State of Evidence.

Background: Adult vaccination coverage remains low in the United States, particularly among racial and ethnic minority populations. Objective: To conduct a comprehensive literature review of research studies assessing racial and ethnic disparities in adult vaccination. Search Methods: We conducted a search of PubMed, Cochrane Library, ClinicalTrials.gov, and reference lists of relevant articles. Selection Criteria: Research studies were eligible for inclusion if they met the following criteria: (1) study based in the United States, (2) evaluated receipt of routine immunizations in adult populations, (3) used within-study comparison of race/ethnic groups, and (4) eligible for at least one author-defined PICO (patient, intervention, comparison, and outcome) question. Data Collection and Analysis: Preliminary abstract review was conducted by two authors. Following complete abstraction of articles using a standardized template, abstraction notes and determinations were reviewed by all authors; disagreements regarding article inclusion/exclusion were resolved by majority rule. The Social Ecological Model framework was used to complete a narrative review of observational studies to summarize factors associated with disparities; a systematic review was used to evaluate eligible intervention studies. Results: Ninety-five studies were included in the final analysis and summarized qualitatively within two main topic areas: (1) factors associated with documented racial-ethnic disparities in adult vaccination and (2) interventions aimed to reduce disparities or to improve vaccination coverage among racial-ethnic minority groups. Of the 12 included intervention studies, only 3 studies provided direct evidence and were of Level II, fair quality; the remaining 9 studies met the criteria for indirect evidence (Level I or II, fair or poor quality). Conclusions: A considerable amount of observational research evaluating factors associated with racial and ethnic disparities in adult vaccination is available. However, intervention studies aimed at reducing these disparities are limited, are of poor quality, and insufficiently address known reasons for low vaccination uptake among racial and ethnic minority adults.

Vaccination Coverage of Privately Insured Children: Comparing U.S. Survey and Administrative Data.

INTRODUCTION: National Immunization Survey-Child data are used widely to assess childhood vaccination coverage in the U.S. This study compares National Immunization Survey-Child coverage estimates with estimates using other supplementary data sources. METHODS: Retrospective analyses in 2021 assessed vaccination coverage of privately insured children for vaccines recommended by the Advisory Committee on Immunization Practices by age 2 years, using the 2015-2018 MarketScan Commercial Claims and Encounters databases and the 2018-2019 Healthcare Effectiveness Data and Information Set. The coverage estimates were compared statistically with those using the 2016-2018 National Immunization Survey-Child. RESULTS: Estimated coverage ranged from 69.9% (≥2 doses of influenza vaccine) to 95.0% (≥3 doses of diphtheria, tetanus toxoids, and acellular pertussis vaccine) using the MarketScan Commercial Claims and Encounters data and from 68.0% (≥2 doses of influenza vaccine) to 92.2% (≥1 dose of measles, mumps, and rubella vaccine) using the Healthcare Effectiveness Data and Information Set. The difference between the MarketScan Commercial Claims and Encounters and National Immunization Survey-Child estimates ranged from 0.1 to 4.3 percentage points and was statistically significant for 6 of the 13 assessed vaccines/doses and percentage of children receiving no vaccinations. The difference between the Healthcare Effectiveness Data and Information Set and National Immunization Survey-Child estimates ranged from 0.4 to 7.2 percentage points and was statistically significant for 6 of the 10 assessed vaccines/doses. CONCLUSIONS: For certain vaccines and populations of interest, the National Immunization Survey-Child, MarketScan Commercial Claims and Encounters, and Healthcare Effectiveness Data and Information Set data might give comparable coverage of privately insured children.

Human papilloma virus vaccination and cervical cancer screening coverage in managed care plans - United States, 2018.

Human papilloma virus (HPV) vaccination for adolescents aged 11-12 years and cervical cancer screening for women aged 21-65 years are recommended to help prevent cervical cancer. The purpose of this study was to describe 2018 National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) data for the United States on HPV vaccination and cervical cancer screening from 275 commercial preferred provider organizations (PPOs), 219 commercial health maintenance organizations (HMOs), and 204 Medicaid HMOs. The Centers for Disease Control and Prevention and NCQA analyzed the data in 2021. The HEDIS® measure for HPV vaccination was the percentage of male and female adolescents aged 13 years who completed HPV immunization (2- or 3-dose series) on or before their 13th birthday. The measure for cervical cancer screening was the percentage of women screened either with cervical cytology within the last 3 years for women aged 21-64 years or with cervical cytology/HPV co-testing within the last 5 years for women aged 30-64 years. Nationally, the mean rate for HPV vaccination in 2018 was 37.8% in Medicaid HMOs, 30.3% in commercial HMOs, and 24.9% in commercial PPOs. The mean rate for cervical cancer screening was 75.9% in commercial HMOs, 72.6% in commercial PPOs, and 60.3% among Medicaid HMOs. Medicaid HMOs reported higher HPV vaccination rates but lower cervical cancer screening rates than commercial plans. These differences raise questions about explanatory factors and how to improve prevention performance by plan category.

Coverage and Timing of Influenza Vaccination Among Privately Insured Pregnant Women in the United States, 2010-2018.

OBJECTIVE: Pregnant women are at increased risk of serious complications from influenza and are recommended to receive an influenza vaccination during pregnancy. The objective of this study was to assess trends, timing patterns, and associated factors of influenza vaccination among pregnant women. METHODS: We used 2010-2018 MarketScan data on 1 286 749 pregnant women aged 15-49 who were privately insured to examine trends and timing patterns of influenza vaccination coverage. We examined descriptive statistics and identified factors associated with vaccination uptake by using multivariate log-binomial and Cox proportional hazard models. RESULTS: In-plan influenza vaccination coverage before delivery increased from 22.0% during the 2010-2011 influenza season to 33.2% during the 2017-2018 influenza season. About two-thirds of vaccinated women received the vaccine in September or October during each influenza season. For women who delivered in September through May, influenza vaccination coverage increased rapidly at the beginning of influenza season and flattened after October. For women who delivered in June through August, influenza vaccination coverage increased gradually until February and flattened thereafter. Most vaccinated women who delivered before January received the vaccine in the third trimester. Increased likelihood of being vaccinated was associated with age 31-40, living in a metropolitan statistical area, living outside the South, enrollment in a consumer-driven or high-deductible health plan, being spouses or dependents of policy holders, and delivery in November through January. CONCLUSIONS: Despite increases during the past several years, vaccination uptake is still suboptimal, particularly after October. Health care provider education on timing of vaccination and recommendations throughout influenza seasons are needed to improve influenza vaccination coverage among pregnant women.

Why Aren't We Achieving High Vaccination Rates for Rotavirus Vaccine in the United States?

BACKGROUND: Rotavirus vaccine (RV) coverage levels for US infants are <80%. METHODS: We surveyed nationally representative networks of pediatricians by internet/mail from April to June, 2019. Multivariable regression assessed factors associated with difficulty administering the first RV dose (RV#1) by the maximum age. RESULTS: Response rate was 68% (303/448). Ninety-nine percent of providers reported strongly recommending RV. The most common barriers to RV delivery overall (definite/somewhat of a barrier) were: parental concerns about vaccine safety overall (27%), parents wanting to defer (25%), parents not thinking RV was necessary (12%), and parent concerns about RV safety (6%). The most commonly reported reasons for nonreceipt of RV#1 by 4 to 5 months (often/always) were parental vaccine refusal (9%), hospitals not giving RV at discharge from nursery (7%), infants past the maximum age when discharged from neonatal intensive care unit/nursery (6%), and infant not seen before maximum age for well care visit (3%) or seen but no vaccine given (4%). Among respondents 4% strongly agreed and 25% somewhat agreed that they sometimes have difficulty giving RV#1 before the maximum age. Higher percentage of State Child Health Insurance Program/Medicaid-insured children in the practice and reporting that recommendations for timing of RV doses are too complicated were associated with reporting difficulty delivering the RV#1 by the maximum age. CONCLUSIONS: US pediatricians identified multiple, actionable issues that may contribute to suboptimal RV immunization rates including lack of vaccination prior to leaving nurseries after prolonged stays, infants not being seen for well care visits by the maximum age, missed opportunities at visits and parents refusing/deferring.

Disparities in COVID-19 Vaccination Coverage Among Health Care Personnel Working in Long-Term Care Facilities, by Job Category, National Healthcare Safety Network - United States, March 2021.

Residents of long-term care facilities (LTCFs) and health care personnel (HCP) working in these facilities are at high risk for COVID-19-associated mortality. As of March 2021, deaths among LTCF residents and HCP have accounted for almost one third (approximately 182,000) of COVID-19-associated deaths in the United States (1). Accordingly, LTCF residents and HCP were prioritized for early receipt of COVID-19 vaccination and were targeted for on-site vaccination through the federal Pharmacy Partnership for Long-Term Care Program (2). In December 2020, CDC's National Healthcare Safety Network (NHSN) launched COVID-19 vaccination modules, which allow U.S. LTCFs to voluntarily submit weekly facility-level COVID-19 vaccination data.* CDC analyzed data submitted during March 1-April 4, 2021, to describe COVID-19 vaccination coverage among a convenience sample of HCP working in LTCFs, by job category, and compare HCP vaccination coverage rates with social vulnerability metrics of the surrounding community using zip code tabulation area (zip code area) estimates. Through April 4, 2021, a total of 300 LTCFs nationwide, representing approximately 1.8% of LTCFs enrolled in NHSN, reported that 22,825 (56.8%) of 40,212 HCP completed COVID-19 vaccination.† Vaccination coverage was highest among physicians and advanced practice providers (75.1%) and lowest among nurses (56.7%) and aides (45.6%). Among aides (including certified nursing assistants, nurse aides, medication aides, and medication assistants), coverage was lower in facilities located in zip code areas with higher social vulnerability (social and structural factors associated with adverse health outcomes), corresponding to vaccination disparities present in the wider community (3). Additional efforts are needed to improve LTCF immunization policies and practices, build confidence in COVID-19 vaccines, and promote COVID-19 vaccination. CDC and partners have prepared education and training resources to help educate HCP and promote COVID-19 vaccination coverage among LTCF staff members.§.

COVID-19 Vaccination Intent, Perceptions, and Reasons for Not Vaccinating Among Groups Prioritized for Early Vaccination - United States, September and December 2020.

As of February 8, 2021, 59.3 million doses of vaccines to prevent coronavirus disease 2019 (COVID-19) had been distributed in the United States, and 31.6 million persons had received at least 1 dose of the COVID-19 vaccine (1). However, national polls conducted before vaccine distribution began suggested that many persons were hesitant to receive COVID-19 vaccination (2). To examine perceptions toward COVID-19 vaccine and intentions to be vaccinated, in September and December 2020, CDC conducted household panel surveys among a representative sample of U.S. adults. From September to December, vaccination intent (defined as being absolutely certain or very likely to be vaccinated) increased overall (from 39.4% to 49.1%); the largest increase occurred among adults aged ≥65 years. If defined as being absolutely certain, very likely, or somewhat likely to be vaccinated, vaccination intent increased overall from September (61.9%) to December (68.0%). Vaccination nonintent (defined as not intending to receive a COVID-19 vaccination) decreased among all adults (from 38.1% to 32.1%) and among most sociodemographic groups. Younger adults, women, non-Hispanic Black (Black) persons, adults living in nonmetropolitan areas, and adults with lower educational attainment, with lower income, and without health insurance were most likely to report lack of intent to receive COVID-19 vaccine. Intent to receive COVID-19 vaccine increased among adults aged ≥65 years by 17.1 percentage points (from 49.1% to 66.2%), among essential workers by 8.8 points (from 37.1% to 45.9%), and among adults aged 18-64 years with underlying medical conditions by 5.3 points (from 36.5% to 41.8%). Although confidence in COVID-19 vaccines increased during September-December 2020 in the United States, additional efforts to tailor messages and implement strategies to further increase the public's confidence, overall and within specific subpopulations, are needed. Ensuring high and equitable vaccination coverage across all populations is important to prevent the spread of COVID-19 and mitigate the impact of the pandemic.

Availability of Adult Vaccination Services by Provider Type and Setting.

INTRODUCTION: Knowledge regarding the benefits for adult vaccination services under Medicaid's fee-for-service arrangement is dated; little is known regarding the availability of vaccination services for adult Medicaid beneficiaries in MCO arrangements. This study evaluates the availability of provider reimbursement benefits for adult vaccination services under fee-for-service and MCO arrangements for different types of healthcare providers and settings. METHODS: A total of 43 Medicaid directors across the 50 U.S. states and the District of Columbia participated in a semistructured survey conducted from June 2018 to June 2019 (43/51). The frequency of Medicaid fee-for-service and MCO arrangements reporting reimbursement for adult vaccination services by various provider types and settings were assessed in 2019. Elements of vaccination services examined in this study were vaccine purchase, vaccine administration, and vaccination-related counseling. RESULTS: Under fee-for-service, 41 Medicaid programs reimburse primary care providers for adult vaccine purchase (41/43); fewer programs reimburse vaccine administration and vaccination-related counseling (33/43 and 30/43, respectively). Similar results were observed for obstetricians-gynecologists, nurse practitioners, and pharmacies. Although 24 fee-for-service (24/43) and 23 MCO (23/34) arrangements cover adult vaccination services in most settings, long-term care facilities have the lowest reported reimbursement eligibility. CONCLUSIONS: In most jurisdictions, vaccination services for adult Medicaid beneficiaries are available for a variety of healthcare provider types and settings under both fee-for-service and MCO arrangements. However, because provider reimbursement benefits remain inconsistent for adult vaccination counseling services and within long-term care facilities, access to adult vaccination services may be reduced for Medicaid beneficiaries who depend on these resources.

Decline in Receipt of Vaccines by Medicare Beneficiaries During the COVID-19 Pandemic - United States, 2020.

On March 13, 2020, the United States declared a national emergency concerning the novel coronavirus disease 2019 (COVID-19) outbreak (1). In response, many state and local governments issued shelter-in-place or stay-at-home orders, restricting nonessential activities outside residents' homes (2). CDC initially issued guidance recommending postponing routine adult vaccinations, which was later revised to recommend continuing to administer routine adult vaccines (3). In addition, factors such as disrupted operations of health care facilities and safety concerns regarding exposure to SARS-CoV-2, the virus that causes COVID-19, resulted in delay or avoidance of routine medical care (4), likely further affecting delivery of routine adult vaccinations. Medicare enrollment and claims data of Parts A (hospital insurance), B (medical insurance), and D (prescription drug insurance) were examined to assess the change in receipt of routine adult vaccines during the pandemic. Weekly receipt of four vaccines (13-valent pneumococcal conjugate vaccine [PCV13], 23-valent pneumococcal polysaccharide vaccine [PPSV23], tetanus-diphtheria or tetanus-diphtheria-acellular pertussis vaccine [Td/Tdap], and recombinant zoster vaccine [RZV]) by Medicare beneficiaries aged ≥65 years during January 5-July 18, 2020, was compared with that during January 6-July 20, 2019, for the total study sample and by race and ethnicity. Overall, weekly administration rates of the four examined vaccines declined by up to 89% after the national emergency declaration in mid-March (1) compared with those during the corresponding period in 2019. During the first week following the national emergency declaration, the weekly vaccination rates were 25%-62% lower than those during the corresponding week in 2019. After reaching their nadirs of 70%-89% below 2019 rates in the second to third week of April 2020, weekly vaccination rates gradually began to recover through mid-July, but by the last study week were still lower than were those during the corresponding period in 2019, with the exception of PPSV23. Vaccination declined sharply for all vaccines studied, overall and across all racial and ethnic groups. While the pandemic continues, vaccination providers should emphasize to patients the importance of continuing to receive routine vaccinations and provide reassurance by explaining the procedures in place to ensure patient safety (3).

Urban-Rural Disparities in Vaccination Service Use Among Low-Income Adolescents.

OBJECTIVE: To access urban-rural disparities in vaccination service use among Medicaid-enrolled adolescents and examine its association with residence county characteristics. STUDY DESIGN: We used the 2016 Medicaid T-MSIS Analytic File to estimate adolescents' use of vaccination services, defined as the proportion of adolescents aged 11-18 years with ≥ 1 vaccination visit in a county. We used linear regression and the Oaxaca-Blinder decomposition method to examine the association between county characteristics and urban-rural disparities in vaccination service use. RESULTS: The analysis included 2,473 counties located in 38 states. The mean proportion of adolescents making ≥ 1 vaccination visit at the county level was low (36.09%) and was lower in rural than in urban counties (31.99% vs. 36.85%, p < .01). The number of primary care physicians (PCPs) was positively associated with vaccination service use in rural counties; in urban counties, % of households without a vehicle was negatively associated with vaccination service use. The decomposition results showed that 66.78% (3.24 percentage points) of the urban-rural disparities in vaccination service use could be attributed to urban-rural differences in the county characteristics included in the study. Characteristics measuring access to care (number of PCPs), social and economic factors (% adults with at least a bachelor's degree and % children in poverty), quality of care (influenza vaccination rates and preventable hospital stays), and demographics (% non-Hispanic black, % Hispanic, and % females) played a role in urban-rural disparities. CONCLUSIONS: Differences in county characteristics could partly explain the observed urban-rural disparities in vaccination service use among low-income adolescents.

Influenza and Tdap Vaccination Coverage Among Pregnant Women - United States, April 2020.

Vaccination of pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can decrease the risk for influenza and pertussis among pregnant women and their infants. The Advisory Committee on Immunization Practices (ACIP) recommends that all women who are or might be pregnant during the influenza season receive influenza vaccine, which can be administered at any time during pregnancy (1). ACIP also recommends that women receive Tdap during each pregnancy, preferably during the early part of gestational weeks 27-36 (2,3). Despite these recommendations, vaccination coverage among pregnant women has been found to be suboptimal with racial/ethnic disparities persisting (4-6). To assess influenza and Tdap vaccination coverage among women pregnant during the 2019-20 influenza season, CDC analyzed data from an Internet panel survey conducted during April 2020. Among 1,841 survey respondents who were pregnant anytime during October 2019-January 2020, 61.2% reported receiving influenza vaccine before or during their pregnancy, an increase of 7.5 percentage points compared with the rate during the 2018-19 season. Among 463 respondents who had a live birth by their survey date, 56.6% reported receiving Tdap during pregnancy, similar to the 2018-19 season (4). Vaccination coverage was highest among women who reported receiving a provider offer or referral for vaccination (influenza = 75.2%; Tdap = 72.7%). Compared with the 2018-19 season, increases in influenza vaccination coverage were observed during the 2019-20 season for non-Hispanic Black (Black) women (14.7 percentage points, to 52.7%), Hispanic women (9.9 percentage points, to 67.2%), and women of other non-Hispanic (other) races (7.9 percentage points, to 69.6%), and did not change for non-Hispanic White (White) women (60.6%). As in the 2018-19 season, Hispanic and Black women had the lowest Tdap vaccination coverage (35.8% and 38.8%, respectively), compared with White women (65.5%) and women of other races (54.0%); in addition, a decrease in Tdap vaccination coverage was observed among Hispanic women in 2019-20 compared with the previous season. Racial/ethnic disparities in influenza vaccination coverage decreased but persisted, even among women who received a provider offer or referral for vaccination. Consistent provider offers or referrals, in combination with conversations culturally and linguistically tailored for patients of all races/ethnicities, could increase vaccination coverage among pregnant women in all racial/ethnic groups and reduce disparities in coverage.

Variability in influenza vaccination opportunities and coverage among privately insured children.

BACKGROUND: Universal influenza vaccination has been recommended since 2010, yet influenza vaccination rates among children aged 6 months to 17 years remain low compared with other routinely recommended childhood vaccines. OBJECTIVE: Assess in-plan vaccination coverage, opportunities, and missed opportunities during the 2016-2017 influenza season. STUDY DESIGN: Retrospective analyses using 2016-2017 MarketScan® data for 2,768,799 privately insured children aged 1-17 years by the end of 2016 who were continuously enrolled in the same insurance plan during the 2016-2017 influenza season (defined as August 1, 2016 through May 31, 2017). We assessed in-plan vaccination coverage (percentage receiving ≥ 1 dose of influenza vaccine from August 2016-May 2017) and vaccination opportunities (percentage with ≥ 1 provider visit between September 2016 - May 2017). Among children who remained unvaccinated at the end of the season, those with ≥ 1 influenza vaccination opportunity between September 2016-May 2017 were determined to have a missed opportunity. RESULTS: In-plan vaccination coverage during the 2016-17 season was 67.7% in infants (born 2015), 49.5% in toddlers (born 2012-2014), 35.0% in school-aged children (born 2004-2011), and 22.3% in teenagers (born 1999-2003). Like vaccination coverage, vaccination opportunities decreased with age (infants: 97.7%, toddlers: 91.9%, school-aged children: 82.6%, teenagers: 79.3%). Among unvaccinated children, 93.1%, 84.1%, 73.6% and 73.6% of each age group had a missed opportunity for influenza vaccination. CONCLUSION: Opportunities for and coverage with influenza vaccination vary even among privately insured children. Along with continued efforts to reduce missed opportunities, effective strategies to bring children to their doctor for annual influenza vaccination are needed, particularly for older children.

State Policies on Access to Vaccination Services for Low-Income Adults.

Importance: State vaccination benefits coverage and access for adult Medicaid beneficiaries vary substantially. Multiple studies have documented lower vaccination uptake in publicly insured adults compared with privately insured adults. Objective: To evaluate adult Medicaid beneficiaries' access to adult immunization services through review of vaccination benefits coverage in Medicaid programs across the 50 states and the District of Columbia. Design, Setting, and Participants: A public domain document review with supplemental semistructured telephone survey was conducted between June 1, 2018, and June 14, 2019, to evaluate vaccination services benefits in fee-for-service and managed care organization arrangements for adult Medicaid beneficiaries in the 50 states and the District of Columbia (total, 51 Medicaid programs). Exposures: Document review of benefits coverage for adult immunization services and supplemental survey with validation of document review findings. Main Outcomes and Measures: Benefits coverage for adult Medicaid beneficiaries and reimbursement amounts for vaccine purchase and administration. Results: Public domain document review was completed for all 51 jurisdictions. Among these, 44 Medicaid programs (86%) validated document review findings and completed the survey. Only 22 Medicaid programs (43%) covered all 13 Advisory Committee on Immunization Practices-recommended adult immunizations under both fee-for-service and managed care organization arrangements. Most fee-for-service arrangements (37 of 49) reimbursed health care professionals using any of the 4 approved vaccine administration codes; however, 8 of 49 programs did not separately reimburse for vaccine administration to adult Medicaid beneficiaries. Depending on administration route, median reimbursement for adult vaccine administration ranged from $9.81 to $13.98 per dose. Median per-dose reimbursement for adult vaccine purchase was highest for 9-valent human papillomavirus vaccine ($204.87) and lowest for Haemophilus influenzae type b vaccine ($18.09). Median reimbursement was below the private sector price for 7 of the 13 included vaccines. Conclusions and Relevance: Even in programs with complete vaccination benefits coverage, reimbursement amounts to health care professionals for vaccine purchase and administration may not fully cover vaccination provision costs. Reimbursement amounts below costs may reduce incentives for health care professionals to vaccinate low-income adults and thereby limit Medicaid adult beneficiary access to vaccination.

Insurance Reimbursements for Routinely Recommended Adult Vaccines in the Private Sector.

INTRODUCTION: Financial concerns are frequently cited by providers as a barrier to adult vaccination. This study assessed insurance reimbursements to providers for administering vaccines to adults in the private sector. METHODS: This study, conducted in 2018, used the 2016 MarketScan Commercial Claims and Encounters Database and included vaccination visits made by adults aged 19-64 years. Four routinely recommended vaccines targeted at adults were included: tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap); tetanus and diphtheria toxoids (Td); zoster; and influenza. The mean reimbursements for vaccine purchase and administration were reported and examined by state, metropolitan statistical area, provider type, and insurance plan type. Using the private vaccine purchase price published by the Centers for Disease Control and Prevention (CDC), the study reported the proportion of vaccination visits receiving reimbursements above the CDC-published price. RESULTS: The mean vaccine administration reimbursement was $25.80 for the first dose and $14.71 for additional doses in the same visit. The mean vaccine purchase reimbursement was $44.15 for Tdap, $25.78 for Td, and $216.05 for the zoster vaccine; the unweighted mean for the four examined influenza vaccines was $17.25. Reimbursements varied widely by state. Vaccine reimbursements exceeded the CDC-published price for most visits where Tdap (71.4%), zoster (87.8%), and three of four influenza (61.5%-88.5%) vaccines were administered but only for 25.8% of visits where Td was given. CONCLUSIONS: On average, reimbursements for administering vaccines to privately insured adults were adequate for most private practices. However, providers' financial concerns may vary across geographic locations.

Association of State Laws With Influenza Vaccination of Hospital Personnel.

INTRODUCTION: Healthcare personnel influenza vaccination can reduce influenza illness and patient mortality. State laws are one tool promoting healthcare personnel influenza vaccination. METHODS: A 2016 legal assessment in 50 states and Washington DC identified (1) assessment laws: mandating hospitals assess healthcare personnel influenza vaccination status; (2) offer laws: mandating hospitals offer influenza vaccination to healthcare personnel; (3) ensure laws: mandating hospitals require healthcare personnel to demonstrate proof of influenza vaccination; and (4) surgical masking laws: mandating unvaccinated healthcare personnel to wear surgical masks during influenza season. Influenza vaccination was calculated using data reported in 2016 by short-stay acute care hospitals (n=4,370) to the National Healthcare Safety Network. Hierarchical linear modeling in 2018 examined associations between reported vaccination and assessment, offer, or ensure laws at the level of facilities nested within states, among employee and non-employee healthcare personnel and among employees only. RESULTS: Eighteen states had one or more healthcare personnel influenza vaccination-related laws. In the absence of any state laws, facility vaccination mandates were associated with an 11-12 percentage point increase in mean vaccination coverage (p<0.0001). Facility-level mandates were estimated to increase mean influenza vaccination coverage among all healthcare personnel by 4.2 percentage points in states with assessment laws, 6.6 percentage points in states with offer laws, and 3.1 percentage points in states with ensure laws. Results were similar in analyses restricted only to employees although percentage point increases were slightly larger. CONCLUSIONS: State laws moderate the effect of facility-level vaccination mandates and may help increase healthcare personnel influenza vaccination coverage in facilities with or without vaccination requirements.

Trends in Tdap vaccination among privately insured pregnant women in the United States, 2009-2016.

BACKGROUND: Infants younger than 6 months are at increased risk of complications and mortality from pertussis infection. In October 2012, the Advisory Committee on Immunization Practices revised its recommendation to include a Tdap dose during each pregnancy, ideally between 27 and 36 weeks gestation. OBJECTIVE: Assess trends in Tdap vaccination coverage among privately insured pregnant women from 2009 to 2016 including timing of Tdap vaccination (before, during, or after pregnancy), trimester of vaccination for women vaccinated during pregnancy, and missed vaccination opportunities for unvaccinated women. Identify factors associated with vaccination during the optimal period of 27-36 weeks gestation. STUDY DESIGN: Retrospective analysis of privately insured women 15-49 years who delivered live births during 2009-2016 conducted using 2009-2016 MarketScan data. Tdap vaccination coverage and the timing of Tdap vaccine administration were assessed for women continuously enrolled from 6 months before pregnancy to 1 month after delivery. Multivariable logistic regression was performed to identify factors independently associated with receipt of Tdap vaccine at 27-36 weeks gestation. RESULTS: Tdap vaccination coverage during pregnancy increased from 0.4% in 2009 to 6.2% in 2012 and to 53.2% in 2016. The proportion of vaccinated women receiving Tdap at 27-36 weeks gestation increased from <10% in 2009 to nearly 90% in 2016, with most vaccination occurring at 27-32 weeks gestation. Women of older age, residing in a metropolitan statistical area, residing outside the South, and having a capitated health insurance plan were more likely to receive Tdap at 27-36 weeks gestation than their counterparts. Among women not vaccinated during pregnancy, 77.7% had a pregnancy-related medical claim between 27 and 36 weeks gestation. CONCLUSION: Tdap vaccination coverage during pregnancy increased significantly from 2009 to 2016, with the greatest increase occurring after the revised Advisory Committee on Immunization Practices recommendation. Most women who did not receive Tdap vaccine had a missed vaccination opportunity during pregnancy, indicating potential for much higher vaccination coverage and consequent infant protection against pertussis.

Primary care physicians' perspectives on respiratory syncytial virus (RSV) disease in adults and a potential RSV vaccine for adults.

BACKGROUND: Deaths attributable to respiratory syncytial virus (RSV) among adults are estimated to exceed 11,000 annually, and annual adult hospitalizations for influenza and RSV may be comparable. RSV vaccines for older adults are in development. We assessed the following among primary care physicians (PCPs) who treat adults: (1) perception of RSV disease burden; (2) current RSV testing practices; and (3) anticipated barriers to adoption of an RSV vaccine. METHODS: We administered an Internet and mail survey from February to March 2017 to national networks of 930 PCPs. RESULTS: The response rate was 67% (620/930). Forty-nine percent of respondents (n = 303) were excluded from analysis as they reported never or rarely caring for an adult patient with possible RSV in the past year. Among respondents who reported taking care of RSV patients (n = 317), 73% and 57% responded that in patients ≥ 50 years, influenza is generally more severe than RSV and that they rarely consider RSV as a potential pathogen, respectively. Most (61%) agreed that they do not test for RSV because there is no treatment. The most commonly reported anticipated barriers to a RSV vaccine were potential out-of-pocket expenses for patients if the vaccine is not covered by insurance (93%) and lack of reimbursement for vaccination (74%). CONCLUSIONS: Physicians reported little experience with RSV disease in adults. They are generally not testing for it and the majority believe that influenza disease is more severe. Physicians will require more information about RSV disease burden in adults and the potential need for a vaccine in their adult patients.