Alexandra M. Stewart

Vaccinating the health-care workforce: state law vs. institutional requirements.

Health-care workers (HCWs) who have direct contact with patients present the primary source of infectious disease outbreaks in health-care facilities.1 Direct contact refers to people who, if they were infected with influenza, could transmit the disease to a patient, either through sharing a 6-foot space with a patient (personto-person contact) or through touching a surface that comes in contact with a patient (equipment-to-patient contact).2 While studies show that maintaining high levels of staff vaccination protects patients, HCWs, and their families from the complications of seasonal influenza,3 mandatory vaccination of HCWs remains highly controversial. This installment of Law and the Public’s Health examines legal issues surrounding immunization of people working in health-care settings.

When Vaccine Injury Claims Go to Court

In February, the National Vaccine Injury Compensation Program released decisions for the first three test cases heard under the programs Omnibus Autism Proceeding. Alexandra Stewart writes that those decisions will have a substantial effect on vaccine policy and practice in the United States and will influence the analysis of more than 5300 pending claims.

Using state laws to vaccinate the health-care workforce.

Influenza outbreaks in health-care settings, attributed to the unvaccinated workforce, have been well described and documented.1 During an average influenza season, 23% of HCWs are infected with the influenza virus, show mild symptoms, and continue to work despite being infectious.2 Those with serological evidence of infection do not consistently recall their illness and may continue to work while infectious.3 These outbreaks have contributed to patient complications or death and increased economic costs to the health-care system.4,5 Between 3% and 50% of exposed patients can be infected, resulting in median mortality that ranges from 16% in a general ward to 33%–60% in a transplant setting.3 Since 1981, the Centers for Disease Control and Prevention (CDC) has recommended that all HCWs receive an annual influenza vaccination.6 Additionally, Healthy People objectives have set a coverage rate goal of 90% by 2020.7

Medicaid provider reimbursement policy for adult immunizations

BACKGROUND State Medicaid programs establish provider reimbursement policy for adult immunizations based on: costs, private insurance payments, and percentage of Medicare payments for equivalent services. Each program determines provider eligibility, payment amount, and permissible settings for administration. Total reimbursement consists of different combinations of Current Procedural Terminology codes: vaccine, vaccine administration, and visit. OBJECTIVE Determine how Medicaid programs in the 50 states and the District of Columbia approach provider reimbursement for adult immunizations. DESIGN Observational analysis using document review and a survey. SETTING AND PARTICIPANTS Medicaid administrators in 50 states and the District of Columbia. MEASUREMENTS Whether fee-for-service programs reimburse providers for: vaccines; their administration; and/or office visits when provided to adult enrollees. We assessed whether adult vaccination services are reimbursed when administered by a wide range of providers in a wide range of settings. RESULTS Medicaid programs use one of 4 payment methods for adults: (1) a vaccine and an administration code; (2) a vaccine and visit code; (3) a vaccine code; and (4) a vaccine, visit, and administration code. LIMITATIONS Study results do not reflect any changes related to implementation of national health reform. Nine of fifty one programs did not respond to the survey or declined to participate, limiting the information available to researchers. CONCLUSIONS Medicaid reimbursement policy for adult vaccines impacts provider participation and enrollee access and uptake. While programs have generally increased reimbursement levels since 2003, each program could assess whether current policies reflect the most effective approach to encourage providers to increase vaccination services.

The Cost of Cost-Sharing: The Impact of Medicaid Benefit Design on Influenza Vaccination Uptake

Prior research indicates that cost-sharing and lack of insurance coverage reduce preventive services use among low-income persons. State Medicaid policy may affect the uptake of recommended adult vaccinations. We examined the impact of three aspects of Medicaid benefit design (coverage for vaccines, prohibiting cost-sharing, and copayment amounts) on vaccine uptake in the fee-for-service Medicaid population 19–64 years old. We combined previously published reports to obtain state Medicaid policy information from 2003 and 2012. Data on influenza vaccination uptake were taken from the Behavioral Risk Factor Surveillance System. We used a differences-in-differences framework, controlling for national trends and state differences, to estimate the effect of each benefit design factor on vaccination uptake in different Medicaid-eligible populations. Each additional dollar of copayment for vaccination decreased influenza vaccination coverage 1–6 percentage points. The effects of covering vaccines or prohibiting cost-sharing were mixed. Imposing copayments for vaccination is associated with lower vaccination coverage. These findings have implications for the implementation of Medicaid expansion in states that currently impose copayments.