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Supplements Bolstering Vaccine Use in the United States Through Pharmacy-Based Services

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.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 (

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

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