Employer Coverage for Immunizations

Helen Darling, PresidentElizabeth Greenbaum, Program Analyst

February 7th, 2006

Center for Prevention

and Health Services

• How does employer-sponsored health plan coverage expand to include new/newly recommended vaccines?

• Process

• Influencing Factors

• This requires first understanding how most employers define preventive service coverage generally.

National Vaccine Advisory Committee: Question

• 242 Employers

Fortune 500 companies and large public sector employers

50 million beneficiaries (U.S. employees, retirees, and their families)

National and Global

• Most are self-insured

Covered by ERISA (Employee Retirement Income Security Act of 1974)

Business Group Membership

Research Project

• Conducted qualitative interviews with 26 benefit managers at member companies (Oct-Nov 2005)*

Questions included: • How do large employers structure their clinical

preventive service coverage?• What influences large employer decision-

making regarding coverage for clinical preventive services?

Business Group Research: Preventive Service Coverage

* Research was supported by a research grant from sanofi pasteur

• Historically, preventive services were considered part of routine care, not insurable events.

• Managed care as prepaid care introduced the concept of coverage for preventive services as “health maintenance organizations’ paid (rewarded) for keeping people healthy.

• Preventive services coverage not a topic of much discussion.

• Employers would be hard pressed to outline the details of what they consider preventive.

Preventive Service Coverage

• All employers cover at least some immunizations for children and adolescents. • Greater perceived value• Closer association with ‘prevention’• Constraints on coverage are limited to age and dollar

amounts

• All employers also cover at least some adult immunizations, although with more conditions - coverage is more restrictive and variable.• Less understood• Seen more as optional health care• Coverage very often limited by age specifications, risk

factors, dollar amounts, vaccine types, and/or access points

Findings: What immunizations are being covered?

Lessons from Meningococcal vaccine.

• Everyone is now covering it. • The message is key.

• “Children and adolescents are especially vulnerable.”

• Health information can travel quickly through many different mechanisms. • Internet, 24/7 media, shared health stories

• Problems with supply complicated delivery. Need to be wary of fostering cynicism.

Findings: What immunizations are likely to be covered?

How is the preventive benefit being defined?

Preventive Service Coverage

0%

10%

20%

30%

40%

50% Employer does it

Employer relies on Health Plan

Employers works cooperativelywith the Health Plan

Historically Determined

Where are employers getting their prevention-specific information?

Preventive Service Coverage

0%

25%

50%

75% From the Health Plan

Assemble it themselves

Professional Organizations

US Preventive Services Task Force

Unknown

• Percent large employers (>1000 employees) reporting the following as an “important reason for covering clinical preventive services:” • 96% - Potential savings (lower HC costs, improved productivity)

• 94% - Employee requests

• 85% - Recommendation of consultant or medical expert

• Large employer immunization coverage rates:

• Childhood - 94%; Flu - 68%

• 20% of all employers offered onsite adult vaccination (flu)

• Employer size is an important factor in coverage for clinical preventive services.

Other Recent Research*

* Bondi MA, et al. (2006) Employer Coverage of Clinical Preventive Services in the United States. American Journal of Health Promotion. 20(3)214-222.

HDHPs may provide IRS-defined preventive services (including immunizations) with no cost sharing or with a deductible that is lower than for other services.

• 65% of surveyed companies offered a HDHP• 46% of those that offer a HDHP cover prevention at

100%

Improved consumerism?

• 76% of companies with a HDHP just providing a particular plan design. They are not seeking plans with comprehensive models for supplementing health education, health information, decision-support, and/or wellness programs.

Impact of Consumer-Directed Health Plans?

For Members:

• Follow Advisory Committee on Immunization Practices (ACIP) & US. Preventive Services Task Force (USPSTF) guidelines.

• Employers can have confidence in ACIP and USPSTF recommendations because they are based on scientific evidence.

• Cover all recommended vaccines at 100%.

• Educate employees and dependents about importance of prevention.

Our Recommendations:

For the National Vaccine Advisory Committee:

• Improve vaccine financing system. We need a system that guarantees we have access to the vaccines we need.

• Increase communication. Employers are especially interested in information about cost and efficacy

• Create user friendly, targeted communications that answer the question “What’s in it for me?”

• Share often, share widely. Employers get their information from a variety of sources.

Our Recommendations: