OutofPocket Costs Associated with Childhood Immunizations

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Out-of-Pocket Costs Associated with Childhood
Immunizations

• Noelle-Angelique Molinari, PhD
• Health Economist
• National Immunization Program, CDC

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Collaborators

• Rich Schieber, MD, MPH
• Mark Messonnier, PhD

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Background
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NIS Data Georgia
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Guide to Community Preventive Services

• 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

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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
200018(1S)97-140
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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

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Purpose
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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

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Methods
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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

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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

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Universe of Potential Payers, Georgia, 2003
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Data Sources
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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

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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)

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Example Private Insurance6 mo old HepB, DTaP,
Hib, IPV, PCV
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Example VFC, Private MD6 mo old HepB, DTaP,
Hib, IPV, PCV
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Example VFC, Health Dept6 mo old HepB, DTaP,
Hib, IPV, PCV
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Per-Child Cost

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

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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
  Georgias 2003 birth cohort

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Results
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Total Costs per Child by Insurance Type Birth
through Age 4
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OOP Costs per Child by Insurance Type Birth
through Age 4
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Costs Associated with Immunization 2003 Georgia
Birth CohortUninsured Go to Private MD
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Costs Associated with Immunization 2003 Georgia
Birth CohortUninsured Go to Health Dept
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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.
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Limitations
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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)

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PossibleImplications
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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

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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?

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Thank you
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Appendix
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Payments Copays by Visit

• Individual Small Group

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Payments Copays by Visit

• Large Group

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Payments Copays by Visit

• Tricare

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Payments Copays by Visit

• Medicaid Peachcare

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Payments Copays by Visit

• Medicare Uninsured

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Cost per Child

• Calculated present value of 7 visits using 3
  discount rate with monthly basis
• r 3, m 12
• Burden in todays dollars of childhood
  vaccinations from birth through age 4

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Total OOP Costs per visit by Insurance type in
Georgia, 2003
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Discounted Total OOP Costs per Child by
Insurance type in Georgia, 2003
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ACIP 2003 Schedule