How Might Immunization Rates Change if Cost Sharing Is Eliminated?

Objectives

There is a debate regarding the effect of cost sharing on immunization, particularly as the Affordable Care Act will eliminate cost sharing for recommended vaccines. This study estimates changes in immunization rates and spending associated with extending first-dollar coverage to privately insured children for four childhood vaccines.

Methods

We used the 2008 National Immunization Survey and peer-reviewed literature to generate estimates of immunization status for each vaccine by age group and insurance type. We used the Truven Health Analytics 2006 MarketScan Commercial Claims and Encounters Database of line-item medical claims to estimate changes in immunization rates that would result from eliminating cost sharing, and we used the Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey to determine the prevalence of coverage for patients with first-dollar coverage, patients who face office visit cost sharing, and patients who face cost sharing for all vaccine cost components. We assumed that once cost sharing is removed, coverage rates in plans that impose cost sharing will rise to the level of plans that do not.

Results

We estimate that immunization rates would increase modestly and result in additional direct spending of $26.0 million to insurers/employers. Further, these payers would have an additional $11.0 million in spending associated with eliminating cost sharing for children already receiving immunizations.

Conclusions

The effects of eliminating cost sharing for vaccines vary by vaccine. Overall, immunization rates will rise modestly given high insurance coverage for vaccinations, and these increases would be more substantial for those currently facing cost sharing. However, in addition to the removal of cost sharing for immunizations, these findings suggest other strategies to consider to further increase immunization rates.Immunization of children against potentially life-threatening illnesses has proved one of the greatest public health successes and one of the most cost-effective medical interventions of the 20th century.^1,2 One barrier to immunization is financial: enrollees seeking immunizations may be confronted with cost sharing (i.e., the contribution consumers make toward the cost of their health care as defined by their health insurance policy) that they are unable or unwilling to pay.^1–8 Approximately 7% of enrollees with private insurance face cost sharing for the administration of immunizations.⁹This barrier will be lowered as part of the Patient Protection and Affordable Care Act (hereafter, ACA), also referred to as the Health Reform Act.¹⁰ Subpart II Section 2713 of the Act, which was enacted in September 2010, requires first-dollar coverage for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).¹¹ First-dollar coverage means that cost sharing in the form of copays, co-insurance, or deductibles will not apply for ACIP-recommended vaccines. The policy intent was to provide financial relief to patients who were previously deterred by financial barriers, encouraging them to obtain vaccinations once these financial barriers were removed.We examined immunization patterns among privately insured children and adolescents under different levels of cost sharing to estimate the effects of removing cost sharing for both the vaccine dose and administration. Children who are uninsured, underinsured for vaccines, or Medicaid eligible qualify for the Vaccines for Children (VFC) program, which offers vaccines at no cost, and were excluded from this analysis. With the passage of the ACA, children will primarily receive vaccines under private insurance or qualify through expanded Medicaid eligibility to receive vaccines through the VFC program. It is estimated that 89% of the population will have private health insurance coverage when health reform is fully implemented in 2022.^12,13 In 2010, 90% of children had health insurance coverage (public or private) at least some time during the year, of which 60% were covered by private insurance.¹⁴Our analysis focused on four vaccines: (1) measles, mumps, and rubella (MMR); (2) heptavalent pneumococcal conjugate (PCV7); (3) human papillomavirus (HPV); and (4) meningococcal conjugate (MCV4). These vaccines present different challenges to uptake based on age recommendation, cost, and integration in the immunization delivery system (15^–19 MMR is also less expensive than newer vaccines. PCV7, which was recommended by ACIP in 2000, is an example of a vaccine that signaled a new era of more expensive vaccines, though it is also integrated into well-child visits. In 2010, a next-generation PCV13 vaccine replaced PCV7, adding six serotypes to the vaccine. Finally, HPV vaccine, recommended for use in 2006, and MCV4, recommended by ACIP in 2005, highlight the challenges of vaccinating adolescents who sporadically access preventive health care.²⁰ HPV vaccine also highlights the challenges of introducing new vaccines that are not only more expensive but also raise questions about social norms and stigma.²¹

Table 1.

Vaccine product characteristics in the U.S. by licensure, indication, school requirement, and recent coverage levelsOpen in a separate window^aU.S. Food and Drug Administration licensure dates of selected vaccines^bCenters for Disease Control and Prevention (US). 2011 National Immunization Survey [cited 2013 Sep 19]. Available from: URL: http://www.cdc.gov/vaccines/stats-surv/nis/nis-2011-released.htm^cCoverage estimates are for PCV13 (surrogate for coverage, as PCV13 is a replacement product to PCV7 licensed in 2010).MMR = measles, mumps, and rubellaPCV7 = heptavalent pneumococcal conjugateMCV4 = meningococcal conjugateHPV = human papillomavirusPCV13 = 13-valent pneumococcal conjugateTo understand the role of cost sharing and its impact on vaccine coverage, we modeled the effects of eliminating cost sharing for select immunizations routinely recommended for children and adolescents and discuss other factors that may be important impediments to immunization.     

Weight gain during the dolutegravir transition in the African Cohort Study

IntroductionDolutegravir (DTG) has become a preferred component of first‐line antiretroviral therapy (ART) in many settings but may be associated with excess weight gain. We evaluated changes in weight and body mass index (BMI) after switch to single‐tablet tenofovir/lamivudine/dolutegravir (TLD) by people living with HIV (PLWH) in four African countries.MethodsThe African Cohort Study (AFRICOS) prospectively follows adults with and without HIV in Kenya, Uganda, Tanzania and Nigeria. Demographics, ART regimen, weight, BMI and waist‐to‐hip ratio were collected every 6 months. Multivariable Cox proportional hazards modelling was used to estimate hazard ratios and 95% confidence intervals (CIs) for factors associated with developing a BMI ≥25 kg/m². Linear mixed effects models with random effects were used to examine the average change in BMI, weight and waist‐to‐hip ratio.ResultsFrom 23 January 2013 to 1 December 2020, 2950 PLWH were enrolled in AFRICOS and 1474 transitioned to TLD. In adjusted models, PLWH on TLD had 1.77 times the hazard of developing a high BMI (95% CI: 1.22–2.55) compared to PLWH on non‐TLD ART. Examining change in weight among all PLWH on ART, participants on TLD gained an average of 0.68 kg (95% CI: 0.32–1.04) more than PLWH on other regimens after adjusting for duration on ART, sex, age, study site and CD4 nadir. Among participants who switched to TLD, the average change in weight prior to TLD switch was 0.35 kg/year (95% CI: 0.25–0.46) and average change in weight was 1.46 kg/year (95% CI: 1.18–1.75) in the year following transition to TLD after adjustment for confounders.ConclusionsElevated BMI and weight gain among PLWH on TLD are concerning safety signals. Implications for the development of metabolic comorbidities should be monitored, particularly if annual weight gain persists during continued follow‐up after transitioning to TLD.     

Perineal endometrioma occurring during pregnancy: a case report

BACKGROUND: Perineal endometrioma has been reported in reproductive-aged women following perineal trauma. The common presentation is a perineal mass with cyclic pain coincident with the menstrual cycle in a woman with a history of perineal laceration. Curative treatment is possible with complete surgical excision. No reports of perineal endometrioma occurring during pregnancy have been published before. CASE: A case of perineal endometrioma occurred during pregnancy. The patient had a perineal mass that enlarged, with worsening pain. CONCLUSION: A perineal endometrioma may progress during pregnancy. Proper diagnosis is important, and treatment with surgical excision should be considered before attempting subsequent pregnancies.     

Infertility and self-rated health among Malawian women

Infertility is prevalent and stigmatized in sub-Saharan Africa. Self-rated health, a subjective indicator that has been consistently related to objectively measured health, may be useful in evaluating the relationship between women’s infertility and health. Data were from surveys conducted from July 2014 to January 2015 with women aged 15–39 years (n = 915) as part of the initial assessment in a cohort study in Lilongwe district, Malawi. We first assessed correlates of self-reported infertility among women in rural Malawi. We then used multiple logistic regression to examine associations between infertility and self-rated health. Of women surveyed, 20 percent had a history of infertility. Compared to women who had not experienced infertility, women with a history of infertility were older (p = 0.05), less educated (p = 0.01), and more likely to report depressive symptoms (p = 0.02) and forced first intercourse (p = 0.02) and to have been previously diagnosed with a sexually transmitted infection (p = 0.05). However, women with a history of infertility were not significantly more likely to report poor self-rated health (adjusted odds ratio: 1.69; 95 percent confidence interval: 0.70–4.07). Infertility was prevalent in our sample of Malawian women but was not significantly related to self-rated health, an instrument widely used in public-health research.     

The pregnancy factor: the prevalence of depression among women living with HIV enrolled in the African Cohort Study (AFRICOS) by pregnancy status

Among Sub-Saharan African women living with HIV (WLWH), pregnancy creates unique stressors that may cause depression. We describe the prevalence of depression among WLWH enrolled in the African Cohort Study (AFRICOS) by pregnancy status and describe factors associated with depression. WLWH < 45 years of age underwent six-monthly visits with depression diagnosed using the Center for Epidemiological Studies-Depression scale. Visits were categorized as “pregnant;” “postpartum” (the first visit made after the last pregnancy visit), and “non-pregnant.” The prevalence of depression was calculated for each visit type and compared using prevalence odds ratios (POR) with 95% confidence intervals (CI). Logistic regression with generalized estimating equations was used to evaluate sociodemographic factors associated with depression. From January 2013 to March 1, 2020, 1333 WLWH were enrolled, and 214 had pregnancies during follow-up. As compared to the prevalence of depression during “non-pregnant” visits (9.1%), depression was less common at “pregnant” (6.3%; POR = 0.68 [CI: 0.42, 1.09]) and “postpartum” (3.4%; POR = 0.36 [CI: 0.17, 0.76]) visits. When controlling for other factors, the visit category was not independently associated with depression. Visit number, study site, employment status, and food security were independently associated with decreased odds of depression. We observed a lower prevalence of depression during pregnancy and the postpartum period than has been previously described among WLWH during similar time points. We observed protective factors against depression which highlight the impact that holistic and consistent health care at HIV-centered clinics may have on the well-being of WLWH in AFRICOS.

     

MRI diagnosis of spontaneous uterine rupture of an unscarred uterus

Spontaneous uterine rupture is a rare, potentially catastrophic complication of pregnancy, and its prompt diagnosis and treatment are essential in limiting morbidity and mortality. Clinical diagnosis is difficult and relies heavily on diagnostic imaging. Radiological diagnosis is also often difficult with most documented cases involving the use of ultrasound and computed tomography. Although magnetic resonance imaging (MRI) is being used more frequently to assess patients, there are few reports illustrating the utility of MRI and its advantages over other imaging modalities in the diagnosis of uterine rupture. This report documents a case of spontaneous uterine rupture diagnosed by MRI in a postpartum patient with an unscarred uterus.