Addressing Barriers to Optimal Community-Based Vaccination

Despite the potential of vaccines to boost public health and reduce healthcare costs, rates of administration—particularly in adults—fall well below target goals.¹ The causes of low adult vaccination rates are multifactorial, given the complex interchange of communication and services in an increasingly complex healthcare system, as well as a host of patient factors. This article probes the many roadblocks to optimal vaccine coverage and how they can be overcome.

Healthcare System and Regulatory Barriers to Optimal Vaccination Rates

Variability in Laws

Healthcare delivery is regulated by the states. Although all 50 states allow pharmacists to administer vaccinations, there exists much variability among them about what is required. Considerations such as the need for a protocol or a prescription, the minimum age limit, and which vaccines pharmacists can provide differ, depending on each state’s regulations.²

The American Pharmacists Association (APhA) and the National Alliance of State Pharmacy Associations conducted a survey of state immunization laws and rules to identify and highlight the variations. In 2015, 31 states required a protocol or prescription before pharmacists were eligible to provide vaccinations, and 21 states, depending on variables such as age and specific vaccine, allow for a protocol, a prescription, or vaccination without a prescriber.³ The survey broke down the results regarding patients’ age and vaccine types, showing that 27 states have no age limitation, and 46 states allow any vaccine type to be administered by pharmacists.³ The variations in limitations are with respect to age ranges from patients aged 5 years or older to those 18 years and older.³Another aspect that differs from state to state is student pharmacists’ ability to administer vaccinations.³ Current information is available via APhA’s Immunization Center webpage (pharmacist.com/immunization-center).

With scope-of-practice laws so different across the country, pharmacists’ ability to fully participate as vaccinators in life-saving vaccination programs can be limited. For example, some states’ regulating authorities might not be aware of pharmacists’ competencies and training when it comes to administering vaccinations, further adding to this barrier.⁴ Pharmacists and pharmacy associations are urged to be active ambassadors for widespread vaccination strategies by getting involved in efforts at all levels and with all relevant stakeholders to advance vaccination scope of practice on behalf of the profession, and more importantly, to improve public health.⁴

Design of Benefit Plans and Reimbursement

There are 2 pieces to the cost of any given vaccination—the vaccine cost itself and the cost of physical administration. It is not unusual for the reimbursement for vaccinations to fall short of the vaccinator’s costs, making this a critical concern among pharmacists and yet another obstacle to their participation.⁴ As mentioned previously, reimbursement is another area in which a general lack of understanding about pharmacists’ ability to provide vaccinations appears to have a negative impact on pharmacy-based immunization services (PBIS).

Health plan designs often lack uniformity in how and where patients can access their pharmacy and medical benefits. Experts have noted that health plan beneficiaries would be better served by receiving vaccination benefits and reimbursement seamlessly, regardless of the provider.⁵ Pharmacists and advocacy groups have endorsed the creation of a uniform system allowing any provider to bill for Centers for Disease Control and Prevention (CDC)-recommended vaccinations, which would eliminate a significant barrier to patients’ receiving vaccination. By simplifying the process for billing, many more pharmacies would be encouraged to begin new programs or expand current vaccination efforts.⁴

Importantly, not all patients have health plans that cover pharmacy-delivered vaccinations, and members may be confused about benefits for which they are eligible.⁶ Because medical and pharmacy benefits do not share a coordinated payment process, it is important that individuals tasked with purchasing benefits understand the implications of how a plan is designed relative to members’ ability to access needed services. As with other aspects of improving adults’ access to vaccination services that require more integration and consistency, streamlined benefit programs would likely make a large, positive impact.⁶ Additionally, increased awareness regarding the capacity of pharmacies to offer vaccination and education regarding immunizations is needed. Payers might also consider including pharmacies in network as a site of vaccination, potentially optimizing access to vaccine coverage. (For additional perspective on benefits design, see article on page 17.)

Acceptance of Alternative Vaccinators, Lack of Integrated Technology

An APhA survey asked pharmacists what percentage of insurance plans they believed to be “nonreceptive” to covering pharmacist-provided vaccinations. Although only 9% to 17% of pharmacists surveyed reported that insurers are nonreceptive, pharmacists face other barriers to their inclusion as in-network or recognized providers by any given carrier.⁷ This is a barrier for any vaccination program that operates outside of a primary care provider’s office.

The lack of shared, integrated technology among healthcare providers presents a huge challenge for consistency and record keeping for individual patients. In the same APhA survey as mentioned previously, pharmacists reported that only 58% of patients provide contact information for their primary care physician, thus making it impossible for them to update an individual’s vaccination status. Despite this lack of integrated technology, more than 60% of pharmacy practice sites reported that they do provide some type of documentation of patients’ vaccinations directly to the primary provider.⁷

System-wide reporting requirements are another inconsistency across states. The CDC’s immunization information system (IIS) keeps track of vaccine doses, yet not all states require those who provide vaccinations to enter this information. Experts warn that without integrated and consistent tracking, the likelihood of under- or overvaccination is higher. Eleven percent of surveyed pharmacists reported that they are not authorized to access state and local immunization registries, and a total of 35% do not track vaccinations in a registry.⁷

Recently, health departments and pharmacists have focused efforts on improving policies around vaccination reporting. According to the APhA, the IIS technology itself presents a barrier to information sharing because it lacks “bidirectional capacity” that would allow pharmacists to access and update vaccination information.⁸

The APhA recommends that all providers who serve adults have a method for accessing and updating patients’ vaccination history, and it adds that providers should refer to IIS to learn about a patient’s vaccination history.⁸ Pharmacists and other care providers are hindered in their ability to maintain up-to-date communication without shared access to these records.⁴ Some health information technology companies are working to improve the technology gap; however, significant advances may not occur until well into the future.⁴

Experts have stated that community pharmacists do not have access to tools that help manage patients—for example, the ability to schedule patients or make specific recommendations based on the patients’ needs and related to their overall health status, other medications they take, or their age.⁴

Patient-Level Barriers

Yearly, vaccine-preventable disease claims 40,000 to 50,000 US adults at a cost of $10 billion to the healthcare system.⁹ The government’s Healthy People 2020 project seeks to enhance adult vaccination rates for routine recommended vaccines. The program set target rates for various populations and specific vaccinations, but instead, data reflect disappointing rates that fall well below those projected.¹

Educational Gaps

Many adults simply lack an awareness that adults need vaccinations, and they are not educated about official recommendations. Experts note that the public does not know the important and beneficial role vaccines play in healthy, low-risk adults.¹⁰ Because adult vaccination is not a public health requirement like childhood immunization, patients do not ask their healthcare providers for vaccination advice or recommendations. In addition, the idea of booster doses is difficult for patients to understand, and even providers have admitted that the vaccination schedules can be complicated to navigate when it comes to finding the correct demographic.¹⁰

In addition to the need for greater awareness about the benefits of vaccines, knowledge gaps remain when it comes to knowledge regarding benefits for vaccines. Despite general awareness about hospitals or physician offices that are “in network,” more awareness efforts are needed to educate patients about vaccine coverage under joint benefits or pharmacy-only benefits, which could potentially enable improved access in community settings.

Safety and Effectiveness

Concerns regarding vaccine safety and effectiveness, as well as misconceptions and myths about vaccination continue to persist. Although misguided beliefs have been countered, and false and faulty research has been debunked, parents commonly believe that a child’s immune system can be “overloaded” if he or she receives multiple vaccines at once.¹¹ It is also assumed that because diseases such as polio have disappeared, vaccinations against them are no longer needed. A common myth about immunization is that “more vaccinated than unvaccinated people get sick,” and that global health has improved because of modern hygiene and better nutrition. Another misconception is that naturally developing an immunity after having an infection is superior to receiving vaccination.¹¹

The CDC website lists many misconceptions about the influenza vaccine that include the following¹²:

• The influenza shot can give you influenza.
• Some shots are better than others.
• It is better to get influenza than the vaccine
• The influenza vaccine makes people sick.
• There are serious reactions to the vaccine.

The CDC also notes public concerns about the influenza vaccine’s effectiveness and how it varies from year to year as well as among different age and risk groups. Still, there are many reasons for all eligible Americans to get an influenza vaccination every year.¹² Influenza vaccination is associated with reduced risk of hospitalization for the virus and sequelae both in young and older people. It is a valuable preventive measure in people who suffer from preexisting health conditions and an important consideration for pregnant women.¹²

Insurance and Cost

Of course, insurance, reimbursement, and costs play a role in adult vaccination rates from both the patients’ and providers’ perspectives. Differences in benefits design can cause confusion. Not all health insurance plans offer a benefit for PBIS, and some plans may not fully cover all recommended vaccinations under pharmacy benefits. Experts often point to the example that the pneumococcal and influenza vaccines are covered under a Medicare subscriber’s Part B medical benefits, but the shingles vaccine is covered under a Medicare subscriber’s Part D prescription benefits. If a patient prefers all his or her vaccinations at a primary care provider’s office, coverage may become a challenge. On the other hand, if a plan limits benefits for vaccinations administered in a pharmacy, patients may have to pay out of pocket. The expense may cause the patient to forego the recommended vaccinations.⁴ Recent surveillance data show that having health insurance and a usual place for getting healthcare are independently associated with a person’s receipt of the most recommended vaccines.¹³

Conclusions

Vaccination coverage levels among US adults are suboptimal, and improvement is needed to counter the negative health consequences associated with vaccine-preventable disease. Many factors converge to create barriers to vaccination, including obstacles at the systemic level and the patient level. Overcoming the variations in state laws and scope-of-practice rules, inconsistent and low reimbursement, and the lack of integrated technology and standards of record reporting will be needed to increase adult vaccination rates. Additionally, intricacies in benefits design could be streamlined to potentially allow optimal opportunities for patients to receive vaccination under pharmacy benefits.

Many adults lack awareness of their need for vaccines or of the current CDC recommendations. Adult patients rely on their healthcare providers to give recommendations for vaccination. To be successful, a vaccination program should provide education and increase awareness using various methods of publicity and promotion. Then, patients can be directed to their options for accessing vaccination services—both traditional and outside of the primary care physician’s office.

1. CDC. Healthy People 2010 Final Review. Hyattsville, MD: National Center for Health Statistics; 2012. cdc.gov/nchs/healthy_people/hp2010/hp2010_final_review.htm. Published 2012. Accessed June 18, 2018.
2. Burson RC, Buttenheim AM, Armstrong A, Feemster KA. Community pharmacies as sites of adult vaccination: a systematic review. Hum Vacci Immunother. 2016;12:12:3146-3159. doi: 10.1080/21645515.2016.1215393.
3. American Pharmacists Association (APhA). Pharmacist administered vaccines: types of vaccines authorized to administer. pharmacist.com/sites/default/files/files/Slides%20on%20Pharmacist%20IZ%20Authority_July_2016%20v2mcr.pdf?dfptag=imz. Updated July 2016. Accessed June 21, 2018.
4. Bach AT, Goad JA. The role of community pharmacy-based vaccination in the USA: current practice and future directions. Integr Pharm Res Pract. 2015;4:67-77. doi: 10.2147/IPRP.S63822.
5. Skelton JB; American Pharmacists Association, Academy of Managed Care Pharmacy. Pharmacist-provided immunization compensation and recognition: white paper summarizing APhA/AMCP stakeholder meeting. J Am Pharm Assoc. 2011;51(6):704-712. doi: 10.1331/JAPhA.2011.11544.
6. Ko KJ, Wade RL, Yu HT, Miller RM, Sherman B, Goad J. Implementation of a pharmacy-based adult vaccine benefit: recommendations for a commercial health plan benefit. J Manag Care Spec Pharm. 2014;20(3):273-282. doi: 10.18553/jmcp.2014.20.3.273.
7. American Pharmacists Association (APhA). Annual Pharmacy-Based Influenza and Adult Immunization Survey 2013. Final Report. Washington, DC: US Department of Health and Human Services National Vaccine Program Office; 2013. pharmacist.com/sites/default/files/files/Annual%20Immunization%20Survey%20Report.pdf. Accessed June 21, 2018.
8. Bonner L. Pharmacists reporting to state immunization registries. APhA website. http://www.pharmacist.com/article/pharmacists-reporting-state-immunization-registries-0. October 29, 2014. Accessed June 21, 2018.
9. Levi J, Schaffner W, Cimons M, Guidos R, Segal LM; Trust for America’s Health, Infectious Disease Society of America (IDSA), Robert Wood Johnson Foundation. Adult Immunization: Shots to Save Lives. Washington, DC: Trust for America’s Health; 2010. healthyamericans.org/assets/files/TFAH2010AdultImmnzBrief13. pdf. Accessed June 21, 2018.
10. Wick JY. Roll up your sleeves: adult immunizations. Pharmacy Times^®. March 13, 2013. pharmacytimes.com/publications/issue/2013/march2013/roll-up-your-sleeves-adult-immunizations. Accessed June 1, 2018.
11. College of Physicians of Philadelphia. Misconceptions about vaccines. historyofvaccines.org/content/articles/misconceptions-about-vaccines. Updated January 25, 2018. Accessed June 10, 2018.
12. Centers for Disease Control and Prevention (CDC). Influenza (Flu). Misconceptions about seasonal flu and flu vaccine. CDC website. cdc.gov/flu/about/qa/misconceptions.htm. Updated October 3, 2017. Accessed June 10, 2018.
13. Williams WW, Lu PJ, O’Halloran A, et al. Surveillance of vaccination coverage among adult populations—United States, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(4):95-102. doi: 10.15585/mmwr.ss6611a1.
14. Human Vaccines & Immunotherapeutics: News. Hum Vaccin Immunother. 2014;10(11):3103-3106. doi.org/10.4161/21645515.2014.995038.
15. Calo WA, Gilkey MB, Shah P, Marciniak MW, Brewer NT. Parents’ willingness to get human papillomavirus vaccination for their adolescent children at a pharmacy. Prev Med. 2017; 99:251-256. doi:10.1016/j.ypmed.2017.02.003.

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