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:
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
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
Employer Health Benefits
Together, employers and health plans hold a strong position of influence over the financial environment of immunization. Employers that offer health benefits often evaluate new health plans (eg, review health plans’ costs, HEDIS results, and preventive coverage) to modify their networks and improve quality outcomes and costs for their employees. In 2018, 61% of employers looked for a new health plan or insurance carrier.22 Employers who recognize the value of preventive services, such as routinely recommended immunizations, may be more likely to invest in health plans that offer this coverage.
Although the Patient Protection and Affordable Care Act (ACA) requires private health insurance policies to reimburse all recommended vaccinations,3 health plans that existed before the enactment of the ACA in 2010 were grandfathered into the program and maintained their original coverage policies. Individuals are still able to select a grandfathered plan for self-insurance and employers can offer grandfathered plans to their employees. According to a 2018 survey conducted by Kaiser Family Foundation, 20% of employers who offer health benefits still offered at least 1 grandfathered health plan to employees, and of those insured employees, 16% had chosen to enroll in a grandfathered plan that year. The percentage of employees on a grandfathered plan had decreased from 36% in 2013.22
For employers that continue to provide grandfathered plans, pretax accounts, such as flexible spending accounts (FSAs), can be offered to employees to pay for health expenditures not covered by insurance. In 2018, of employers providing health benefits, 76% of large companies and 33% of small companies offered employees an FSA.22 In addition, increasing employee understanding of overall benefits may help them choose a plan and/or pretax account best suited for their preventive needs. The International Foundation of Employee Benefits Plans’ Benefits Communication Survey results indicated that although 65% of 341 employers reported that educating their employees about benefits is a high priority, they also reported that they believed only 19% of their employees had a good understanding of their benefits. The biggest challenges employers experienced with educating employees about benefits, they said, were that employees didn’t read the educational materials (80%), didn’t understand the materials (49%), and didn’t recognize the value of the health benefits (31%).23 There is an opportunity for employers to continue to refine communications to employees to enhance engagement and understanding about health benefits.
Employers should recognize the benefits they will accrue if they offer preventive coverage to their employees. Episodes of vaccine-preventable diseases can result in presenteeism (suboptimal performance at work) or absenteeism, both for adults who contract the disease and for those whose children contract the disease and require parental care at home.24 The associated costs can take a substantial toll on employers. For example, influenza accounts for approximately 17 million missed workdays each year, which is associated with $7 billion in annual costs to employers in sick days and lost productivity in the United States.25 Although other vaccines that prevent diseases may not have such an obvious return on investment up front, immunization for a targeted employee base can be far less costly than the treatment and lost productivity associated with the disease (see page 21 for more insights on this). For example, HPV may not be contracted for years, and following infection with the virus, it may take additional years for cervical or another HPV-associated form of cancer to develop. Studies have shown that investing in HPV vaccination offers significant long-term cost benefits to employers and the healthcare system at large.26
Employer Efforts To Increase Immunization Rates
In addition to working with health plans to provide employees with the coverage they need for recommended immunizations, employers can educate employees about immunization, offer onsite vaccination clinics, and support employees who travel overseas for business.
Employers can offer education on vaccination through a variety of channels, including onsite classes, newsletters, and promotional posters and flyers.27 The CDC offers several vaccine education resources on their website that employers can use to educate and increase awareness on immunization within their workforce.27 Materials include vaccine-related handouts, posters, videos, radio public service announcements, web banners, examples of social media posts, and articles that can be repurposed in company newsletters.
Having a sick family member can also affect work productivity, so employers should also be incentivized to educate and increase immunization rates among family members. Efforts can include providing employees with vaccine handouts to bring home to their family and inviting family members to attend an employer-sponsored vaccine clinic at no cost.
Onsite Vaccination Clinics
Employers can improve employee access to vaccinations through on-site vaccination clinics and employee immunization programs.27 A variety of benefits is related to hosting an onsite vaccine clinic, including decreasing the amount of work missed to get vaccinated, increasing vaccination rates (and thus increasing workforce immunity and productivity), improving employee morale, and offering a convenient option for employees who otherwise may not put in the effort to receive vaccinations elsewhere.27
The CDC’s National Adult and Influenza Immunization Summit created standardized guidelines for employers to follow for onsite clinics. The guidelines include a vaccination clinic organization pledge that employers can sign to indicate their commitment to providing safe and effective vaccination clinics. It also includes a best-practices checklist that provides clear steps regarding vaccine shipment, storage, and handling; clinic preparation and supplies; vaccine handling, preparation, administration, and documentation during the clinic; and postclinic actions and documentation.28,29
Employee engagement with onsite vaccination clinics can be increased in a variety of ways. Employers can incentivize participation through department competitions or providing refreshments at the clinic. Communications about the vaccination clinic can involve posters, articles in company newsletters, direct emails from business leaders to employees, and social media.27 The location of the vaccine clinic in the workplace can also influence level of employee engagement. A study involving 1801 employees found that the probability of vaccination increased by 6.4 percentage points if the employee walked past the clinic for reasons other than vaccination; the base proximity of the vaccine clinic did not appear to make a difference in predicting vaccination probability.30
For employees who are unable to attend an onsite vaccination clinic, employers can share the CDC/HHS vaccine finder tool and offer flexibility with taking time off to receive recommended vaccinations.27
International Travel Health Programs
In 2017, approximately 4.8 million people in the United States traveled internationally for business, which, depending on the countries visited, exposed them to vaccine-preventable diseases that are not present in the United States.31 Health insurance costs for international business travelers are up to 70% higher than those of their counterparts who did not travel.31 Employers have multiple motives to help protect the health of their employees who travel overseas: In addition to simply wanting to keep their employees safe, they should also want to protect themselves from decreased employee work days, increased costs, and legal settlements.31 Businesses, particularly larger corporations, have created international travel health programs; these not only help reduce emergency medical evacuations and hospitalizations, but also increase employee productivity and reduce costs.31 An employee should attend a consultation with a provider before international travel, during which all required and recommended vaccinations for the country of travel are discussed and can be administered. Additionally, the employer should cover all costs associated with business-related travel and with any related follow-up consults.31
Health plans and employers, in partnership and separately, hold unique positions in the national effort to improve vaccination coverage. Health plans, in addition to advocating and educating, can engage in vaccine research with claims data and influence the cost-reimbursement structure of vaccinations. Employers, with direct, near-daily access to their employees, can make a substantial difference through vaccine education and onsite clinics; they can also ensure that their employees have access to health benefits that cover vaccination. Health plans and employers must continue to combine forces with clinicians, pharmacists, state and federal agencies, and the private sector in an effort to raise the bar for quality healthcare provision and to ultimately decrease the rate of occurrence of vaccine-preventable diseases in the United States.