The Global Healthy Living Foundation (GHLF) recently published a policy paper authored by Robert Popovian, PharmD, MS, Founder, Conquest Advisors and GHLF’s Chief Science Policy Officer, “Challenges in Adult Vaccination: Policy Strategies for Sustaining Access and Supply,” regarding the benefits associated with current vaccine access and the payment model for adult vaccination in the United States. The paper also covers potential negative impacts of Pharmacy Benefit Managers (PBMs) potentially subverting the vaccine reimbursement landscape.
The report notes that vaccines are “one of the most clinically meaningful and cost-beneficial interventions in healthcare” and that every vaccine is unique “due to molecular variation, differing indications, and side-effect profiles.” Currently, the report notes, insurers are required to provide coverage and reimbursement for recommended vaccines without any out-of-pocket costs to eligible individuals, and that the current “payment and coverage model for adult vaccines has led to robust access for all patients with minimal impact on healthcare spending in the U.S.”
In the report, Dr. Popovian highlights the practices of PBMs that may limit patient access and disrupt the supply of vaccines. In particular, PBMs add a layer of complexity to the vaccine distribution process by enforcing restrictive policies involving delayed payments, complex authorization processes, or insufficient reimbursement rates. These practices can not only impact the bottom line of pharmacies – and their continued financial stability – but also limit the vaccines offered by individual pharmacies.
The report also highlights the importance of pharmacists, with pharmacists often serving as the most readily available health care providers, particularly in underserved communities. The paper details concerns over PBM policies potentially undermining this accessibility to pharmacists, with a significant impact on lower-income neighborhoods and minority communities, where pharmacists play an important role in vaccination.
The paper emphasizes the importance of safeguards in place to prevent PBMs from limiting competition and/or restricting access to vaccines. It also highlights the continued overage of adult vaccines by insurers (public and private), an important component to easy vaccine access and one that allows patients to receive vaccinations at local pharmacies without incurring out-of-pocket costs.
“Pharmacists are tasked with providing essential health services, including vaccinations,” said Dr. Popovian. “Suppose PBMs are allowed to impose access restrictions by providing inadequate reimbursement for the sole purpose of profiteering. Such actions would disrupt the current vaccination ecosystem in pharmacies, which ensures strong patient access, and critically, could endanger the long-term vaccine supply.”
Popovian notes that while PBMs may not be a prime choice for vaccines, there are several policy considerations that should be considered, including: encouraging competition for vaccines, maintaining the current model of price negotiation between retail pharmacies and manufacturers, continuing the current vaccine access model, and prioritizing patient-centered care through pharmacists.