Melanie Ehni Mouzoon, M.D., F.A.A.P Managing Physician for Immunization Practices and Travel Medicine, Kelsey-Seybold Clinic
1. Be able to name at least one barrier to adult immunization related to each of the following: Healthcare System, Medical Practice, Patient. 2. State at least one financial disincentive to vaccinate 3. Know at least one intervention for each of the areas of concern (Healthcare system, medical practice, patient actions) that can improve adult immunization rates
No routine for adults to be given or to keep shot records Adult records not often included in immunization registries Immunization history scattered over numerous providers in uncoordinated health care system Old records unavailable due to provider retirement, uncertainty of which providers used, immunizations given in places where records are not maintained (health fairs,etc.)
Specialty Medical Associations may not accept their role as vaccinators or promote immunization Should surgeons update Td before surgery? Should ENT physicians offer Prevnar? Should cardiologists and pulmonologists offer influenza and pneumococcal vaccines? Providers who do not offer vaccines may write prescriptions for vaccination at pharmacies, but will not have a record of the immunization in the chart.
Little or no vaccination training in residency, especially in OB/Gyn, subspecialty practices No incentive or practice standard to stock vaccines in many types of practices (especially subspecialty practices) No routine pattern of asking about vaccination status at routine visits or even checkups
Most adults unaware they may need vaccines Most adults believe they are low risk for vaccines recommended for them Young adults get healthcare irregularly Men get well exams less often than women Females may only see OB/Gyn physicians who may not promote vaccination Some adults only see specialists, for example endocrinologists if diabetic
Fail to ask about vaccines at physician visits Fail to ask for travel medicine advice Fail to keep personal vaccination records Fail to receive the vaccine recommended if sent elsewhere (to immunization nurse, pharmacy, back to primary care physician). Refuse vaccines due to cost, inconvenience, fear, misinformation
Many adults are uninsured, and there is no VFC program for those over 18 317 funds are not available for private practice Some insurance does not cover immunization in general or specific vaccines, or may require pre-authorization for some individuals Vaccines are expensive and add cost to the visit unrelated to the reason the patient has come in, so may be refused if paying out of pocket or still paying high deductible
Medicare covers TIV (flu) and PPS-23 under medical benefits, but Zostavax and Td or Tdap as a pharmacy benefit (more cost to patient) Pregnancy (and surgery) services are bundled, and if the woman is vaccinated it either Reduces the margin the provider receives Causes her to have to pay a copay for a visit she was not planning to pay (to the OB/Gyn at a higher specialty rate), or Causes her to pay out of pocket for the vaccine
Special refrigerator, thermometer, temp logs, storage requirements and monitoring required for biologics Special training required for nurses and medical assistants to give vaccinations Vaccines have a very high up front cost with a potentially long stock period, and wastage due to expiration or temperature control issues such as a power outage is incredibly expensive and not entirely reimbursable or insurable
Documentation and consent requirements higher than for many medicines Heightened concerns of public about vaccine safety require more time from physician and staff to educate and promote vaccines Coding for reimbursement is confusing and recently has changed from year to year, and insurers may take time to adopt new codes or delay reimbursement if coding is wrong.
Healthcare legislation has already increased the number of insured adults and children, and will continue to do so if not repealed Vaccination reimbursement is promoted and more standardized under new legislation Immunization Information Systems are now beginning to include adults
Accountable Care Organizations will be required to show increased immunization rates Incentives to adopt Electronic Medical Records should improve availability of adult immunization records and allow best practice alerts to offer needed immunizations at every visit
Immunization training and promotion is now adopted by ACOG and other specialty areas are showing more support Multispecialty group practices are changing the standard for what should be offered and provide a competitive impetus to adoption of vaccination as a standard of care EMRs are increasingly prepackaged with immunization alerts as HEDIS and other practice assessments focus on immunizations
CDC has stepped up their game and there is more media coverage nationally, at least about certain vaccines and new recommendations On-hold messaging, outgoing Televox, mail reminders are more affordable and available Internet communication with physician offices, twitter feeds, facebook postings, blogs and text messages are all useful ways to educate and remind patients of immunization recommendations TIP and each of us can make ourselves available for media presentations when vaccines or vaccine-preventable diseases are in the news.
Advocate for inclusion of adults in immunization information systems Advocate for inclusion of immunization coverage under insurance before deductible is met (as a public health issue) Encourage adult patients to have a personal immunization record, to put a shot record on their ipad or smartphone by photographing their medical record Be sure that immunization alerts and IIS linkups are included in EMRs purchased for offices and hospitals
Melanie.Mouzoon@Kelsey- Seybold.com 713-442-0128 (office) Kelsey-Seybold Clinic 7900 Fannin, Suite 2100 Houston, TX 77054