Out-of-Pocket Costs Associated with Childhood Immunizations

1. Out-of-Pocket Costs Associated with Childhood Immunizations Noelle-Angelique Molinari, PhD Health Economist National Immunization Program, CDC

2. Collaborators • Rich Schieber, MD, MPH • Mark Messonnier, PhD

3. Background

4. NIS Data: Georgia

5. Strongly recommends reducing out-of-pocket (OOP) costs to increase vaccination rates Suggests this may be accomplished by: Providing free vaccine Reducing administration costs Providing insurance coverage Reducing copayments at POS Guide to Community Preventive Services

6. Benefits of Lower OOP Costs • Increased coverage • Law of Demand • price decline leads to increased quantity demanded • 13 studies* show decrease OOP associated with increase coverage • Encourages medical home for all care • IZ more prompt & timely * Briss PA et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18(1S):97-140

7. Problems of Higher OOP Costs • Multiple IZ providers, esp. health depts. • Lower coverage rates • Push to seek care outside medical home • Disparity in OOP costs may directly result in disparity in coverage

8. Purpose

9. Purpose • To estimate OOP costs associated with childhood IZ: • Under current standards of care received at medical home • For a defined, large, heterogeneous population • To determine whether disparities exist by • Insurance status • Payer types

10. Methods

11. Assumptions: Optimal Care • Georgia 2003 birth cohort • No change in insurance distribution across age or over time • Full compliance with AAP 2003 vaccine schedule • Each child receives current standard of care in medical home • Each child receives shots as soon as eligible

12. Assumptions: Optimal Care • 7 visits from birth through age 4 • Each private MD visit includes well-child exam, vaccine, and administration fee • No new combination vaccines used • No submitted charges are disallowed by insurance • No shortages • Relative prices remain constant over time

13. Universe of Potential Payers, Georgia, 2003

14. Data Sources

15. Total Cost per Visit Total Cost = (WC Exam Fee) + (Vax Fee) + (# Vax) (Vax Admin Fee) • WC Exam = Well-child exam fee • Vax Fee = Vaccine price to patient • # Vax = No. of vaccines given that visit • Vax Admin Fee = Fee charged for administering shot

16. Out-of-Pocket (OOP) Cost per Visit OOP = Copay(WC Exam)+ Copay(Vax) + Copay(Vax Admin)(#Vax) • Copayment is the amt. of total charges a patient pays • Copay can be either: • Flat fee ($10) • Rate (10%)

17. Example: Private Insurance6 mo old HepB, DTaP, Hib, IPV, PCV

18. Example: VFC, Private MD6 mo old HepB, DTaP, Hib, IPV, PCV

19. Example: VFC, Health Dept6 mo old HepB, DTaP, Hib, IPV, PCV

20. Per-Child Cost • Sum all costs over 7 visits • Discount to obtain present value of per-child cost in 2003 dollars

21. Cost for Georgia 2003 Cohort • Multiply • OOP cost-per-child for each insurance category • # children in that insurance category (CPS 2004 data) • Result is population-weighted estimate of OOP costs associated with childhood immunization for Georgia’s 2003 birth cohort

22. Results

23. Total Costs per Child by Insurance Type Birth through Age 4

24. OOP Costs per Child by Insurance Type Birth through Age 4

25. Costs Associated with Immunization 2003 Georgia Birth CohortUninsured Go to Private MD

26. Costs Associated with Immunization 2003 Georgia Birth CohortUninsured Go to Health Dept

27. OOP Costs & IZ Coverage • Coverage negatively correlated with OOP costs * Phil Smith provided information from NIS 2003 on GA IZ coverage rates by plan type.

28. Limitations

29. Data are Not Perfect • HIP Enrollment survey 61% response (enrollment per plan) • Tricare weights are estimated, not based on enrollment • Copayments are based on benefit plan descriptions rather than actual reimbursements (except Large group)

30. PossibleImplications

31. Implications… • Decreasing OOP costs will increase coverage • Plan designs are skewed toward low OOP costs • VFC reduces OOP cost & thereby reduces insurance-based disparities • Uninsured still face high OOP costs • Medicaid & SCHIP low OOP cost encourages IZ among low income children

32. Policy Implications • Are child vaccinations (not just vaccines)based on an entitlement or a discount program? • How might IZ coverage change with decreased availability of public health clinics? • Funding is not keeping pace with Medicaid/ SCHIP expansion. How will this affect IZ coverage?

33. Thank you

34. Appendix

35. Payments & Copays by Visit • Individual & Small Group

36. Payments & Copays by Visit • Large Group

37. Payments & Copays by Visit • Tricare

38. Payments & Copays by Visit • Medicaid & Peachcare

39. Payments & Copays by Visit • Medicare & Uninsured

40. Cost per Child • Calculated present value of 7 visits using 3% discount rate with monthly basis • r = 3%, m = 12 • Burden in today’s dollars of childhood vaccinations from birth through age 4

41. Total & OOP Costs per visit by Insurance type in Georgia, 2003

42. Discounted Total & OOP Costs per Child by Insurance type in Georgia, 2003

43. ACIP 2003 Schedule