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Supplements New Directions in Immunization Awareness and Engagement

The Role of Health Plans and Employers in Fostering Vaccine Engagement

Rates for routinely recommended vaccinations fall well below target goals in the United States, particularly among adults,1 and improving vaccination rates has required engagement across all wings of the healthcare spectrum. For example, physicians and pharmacists, with direct access to patients, make an impact through vaccine education, recommendation, and administration.2 As discussed in the previous article in this publication, government and private sectors have developed various funds, incentives, and initiatives to help address financial barriers that contribute to suboptimal vaccination rates, and all nongrandfathered private health plans now cover routinely recommended vaccines without a co-pay or co-insurance.3 Health plans and employers together determine the cost and scope of private insurance coverage for employees, and both can also engage in patient and provider education, advocacy, and research. Although these 2 groups may receive less attention than others do for the roles they play in immunization, their engagement is crucial in the ongoing efforts toward decreasing vaccine-preventable disease.

Health Plan Efforts to Increase Immunization Rates

Health plans recognize the importance of vaccinations4 and are held accountable to achieving improved vaccination rates for their members through participation in quality tracking programs, such as the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is used by more than 90% of health plans in the United States to measure performance.5 Of the 90 measures HEDIS established to benchmark quality outcomes, several are associated with immunizations, including adult immunization status and prenatal immunization status—measures that were added in 2019 with funds from the HHS National Vaccine Program.6

Roadmap for health plans
The National Vaccine Program was established in 2010 to provide broad guidance on decreasing vaccine-preventable diseases through the year 2020. 7 To optimize engagement with HHS’s newly established National Adult Immunization Plan, American’s Health Insurance Plans (AHIP), which is a health plan association that leads public policy strategies related to healthcare coverage,8 spearheaded a roundtable discussion about the challenges related to increasing immunization rates. The roundtable participants included health plan leaders, federal officials, public health professionals, pharmacists, clinicians, and consumers. Their subsequent report included a review of how stakeholders across the immunization ecosystem can work together to improve vaccination coverage. For health plans, the stakeholders recognized an opportunity to partner with physicians, public health organizations, pharmacies, and other sites of care to help increase vaccine education and access for patients who need them. Specific efforts that could be implemented by health plans include the following4:
  • Offer value-based incentives for providers who improve vaccination rates among their patients.
  • Partner with providers to make sure vaccines are recommended during office visits and appropriate resources are available to increase vaccine administration.
    • Support providers with a streamlined claims submission process to ensure timely reimbursements.
    • Increase provider and member access to information systems to identify immunization status.
    • Give providers data on coverage rates and vaccination gaps to better track patients who are not up to date on their vaccines.
  • Identify disparities in immunization by reviewing adult immunization status during transitions of care.
  • Include immunization screenings and education throughout enrollment processes, wellness programs, and disease management programs.
  • Increase communication and education to encourage members to receive appropriate vaccines.
    • Use mail and phone calls to remind members of vaccines that are due.
In 2019, AHIP submitted a statement to the Senate Committee on Health, Education, Labor, and Pensions that emphasized the importance of a focus on vaccinations, referencing the 2015 stakeholder roundtable and stating their readiness to work with the committee and other stakeholders to improve the rates of disease-preventing vaccinations.9

Provider and patient education and incentives
Low levels of vaccination knowledge and vaccination familiarity among both patients and providers have contributed to immunization rates that fall below target goals.10 Health plans can play a significant role in vaccine education and awareness by engaging with and incentivizing providers and health plan members. For example, a Pittsburgh-based health plan with almost 4.6 million members actively educates providers, young patients, and parents about the safety and efficacy of the human papilloma virus (HPV) vaccine 2-vaccine series.11 Although HPV vaccination has reduced the rate of HPV-related cancers by 86% among teen girls as they get older,12 providers’ knowledge on HPV is generally low, which results in low rates of recommendations for HPV vaccination.13 To enhance provider engagement, the health plan implemented a quality metric and financial incentives related to HPV vaccination. The health plan encourages providers to educate age-appropriate young patients and their parents on the value of HPV vaccination and sends providers a list of members turning 13 years old within the following 6 months to help providers flag patients who may benefit from outreach and education. To increase patient engagement, the health plan sends letters to members aged 9 to 12 years to either educate them on the importance of HPV vaccination or encourage them to complete the vaccination series. Parents also receive mail from the health plan on the vaccine’s safety and efficacy in preventing cancer.11

Targeting children and adolescents with vaccine education may offer an underutilized opportunity to improve population-level understanding of immunizations, including safety and benefits. Children who receive health information from sources such as school may influence the way parents understand and act on health-related decisions. A study published in 2019 outlined the different age-appropriate channels that organizations, including health plans, could leverage to send evidence-based vaccine messages to children and adolescents during different stages of development. For children aged 5 to 7 years, health plans can use television advertisements and online videos to send immunization messages. For children aged 7 to 10, messaging channels can expand to include mobile apps and educational shows. For tweens aged 10 to 13, channels can also incorporate social media and the internet (including interactive games). Adolescents aged 13 to 18 could be receptive to personalized messages received through social media campaigns and information videos that involve celebrities.14

Monetary or nonmonetary incentives for health plan members can also help drive an increase in vaccination rates. Using patient or family incentive rewards for vaccination is recommended by the Community Preventive Services Task Force (CPSTF).15 Health plans can use rewards to incentivize members to complete tasks such as receiving a vaccine or completing a vaccination series. Incentives are typically small, involving items such as gift cards or food vouchers. Results from a systematic review conducted by the CPSTF indicated that vaccine incentive programs across public health settings and public and private partnerships contributed to an increase in vaccination rates by a median of 8 percentage points.16

The Value of Vaccine Claims Data From Health Plans

By having in their possession the health records of individual members that capture medical encounters and treatment, health plans are uniquely positioned to offer comprehensive data for vaccine tracking and research purposes. The AHIP roundtable report noted the value of using health plan claims to confirm gaps in individuals’ vaccinations indicated within immunization information systems (IIS).4

Operated by state and local health agencies, IIS are computerized databases that consolidate immunization information into a centralized source. IIS can be used both to identify an individual’s immunization history at a specific point of care and to aggregate deidentified data on individuals for surveillance and public health goals related to vaccination.17 IIS can also be used to notify patients when they are due for a vaccine. To ensure accuracy and comprehensiveness of IIS data, the AHIP roundtable report suggested that health plans gain greater access to IIS to validate immunization gaps, particularly for patients who change health plans or receive vaccines at alternative sites of care.4 To enhance accuracy further, vaccine data from IIS can be compared with data from additional sources. Results from a recent study suggested that, by comparing data among a national IIS, a health system electronic health record (EHR), and a community pharmacy database, information gaps were identified (particularly in the pharmacy database) and vaccine histories with a higher degree of accuracy were established.18

Vaccine Safety
Safety standards for vaccines in the United States are very high. Health plans’ claims data play an important role in the vaccine safety tracking system in the United States, which is among the world’s most advanced systems for monitoring vaccine safety. The tracking system is composed of several subsystems, of which 2 heavily rely on data from health plans to identify possible safety issues related to vaccines.19 First, the Vaccine Safety Datalink (VSD), which involves a partnership between the CDC and 8 health plans and other healthcare organizations, uses EHR data for tracking potential adverse effects (AEs) from vaccines and conducts studies on serious AEs related to vaccination. The VSD tracks the safety of both new vaccines and those that experience changes to administration recommendations.20 Second, the Post-licensure Rapid Immunization Safety Monitoring System (PRISM) is part of the FDA’s Sentinel Initiative, which monitors medical products after they are licensed for use, and it draws from claims databases from health plans to examine the safety of licensed vaccines.19 The value of this subsystem was demonstrated during the 2009 H1N1 influenza pandemic. During this time, 5 health plans and 9 IIS provided PRISM with records on more than 2.6 million doses of the H1N1 vaccine, which were used to track and confirm the safety of the vaccine within the first 2 weeks of administration.21



 
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