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Medicare: Many Factors, Including Administrative Challenges, Affect Access to Part D Vaccinations

GAO-12-61 Published: Dec 15, 2011. Publicly Released: Dec 15, 2011.
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What GAO Found

Many of the almost 22 million Medicare beneficiaries age 65 and older who were enrolled in Medicare Part D in 2009 did not receive the routinely recommended vaccinations covered by Part D. CDC national survey data for 2009 show that 11 percent of Medicare beneficiaries age 65 and older had received a shingles vaccination and 53 percent had received a Td (tetanus and diphtheria) vaccination—the routinely recommended vaccinations covered under Part D. Medicare data for 2007 through 2009 show that relatively few Part D beneficiaries received these vaccinations under Part D—5 percent for shingles and less than 1 percent for Td or Tdap (which includes protection against pertussis). These data suggest that beneficiaries either received vaccinations prior to enrolling in Medicare or, once enrolled, used other health coverage or paid out of pocket for these vaccinations.

A multitude of factors affect beneficiaries’ access to routinely recommended Part D-covered vaccinations, particularly the low percentage of physicians and pharmacies that stock the relatively new shingles vaccine. Most physicians do not stock the shingles vaccine due to factors such as the cost of purchasing a supply and Part D billing challenges. More than half of physicians refer beneficiaries to pharmacies to purchase the vaccine—which may require beneficiaries to transport the vaccine back to the physician to be administered. Physicians recommend shingles vaccinations less often than other vaccinations, and even when they recommend them, beneficiaries often decline them. At the same time, due in part to a limited supply of the shingles vaccine, only about one-third of pharmacies nationwide stock it. Beneficiaries’ cost sharing—which averaged $57 for a shingles vaccination in 2009—and challenges with obtaining reimbursement from Part D plans were other reported deterrents to beneficiaries’ obtaining Part D vaccinations.

Many stakeholders—government agencies, advisory bodies, and professional organizations—have raised concerns about the administrative challenges associated with Part D and have recommended actions to improve access to Part D vaccinations. The Centers for Medicare & Medicaid Services has issued guidance on a number of approaches to help address administrative challenges, but stakeholders report that additional steps are needed, including broader use of web-based systems, that could provide real-time access to allow physicians to verify beneficiary coverage and bill Part D plans.

Why GAO Did This Study

Vaccinations can prevent diseases and improve the quality of life for Medicare beneficiaries. Vaccinations for flu and pneumonia are covered by Medicare’s Part B physician and outpatient service benefit. Since 2006, Medicare’s Part D prescription drug benefit covers other routinely recommended vaccinations, such as the shingles vaccination. Part D typically contracts with pharmacies, but not physicians, for covered vaccinations. The Patient Protection and Affordable Care Act required GAO to study Medicare beneficiary access to routinely recommended vaccinations covered under Part D. GAO examined (1) the extent to which beneficiaries have received Part D-covered vaccinations, (2) factors affecting beneficiary access to vaccinations, and (3) any findings and recommendations of government agencies and other stakeholders to increase access to Part D-covered vaccinations. To do this, GAO (1) analyzed Centers for Disease Control and Prevention (CDC) national health survey data and Medicare data; (2) surveyed physicians, pharmacies, and state beneficiary assistance programs nationwide; and (3) convened a facilitated discussion with stakeholder groups.


Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To help improve the ability of Medicare beneficiaries to obtain routinely recommended vaccinations, the Administrator of CMS should explore options and take appropriate steps to address administrative challenges, such as physicians' difficulty in verifying beneficiaries' coverage and billing for Part D-covered vaccinations.
Closed – Not Implemented
CMS did not explore options and take appropriate steps to address the administrative challenges we identified in our report, such as physicians? difficulty in verifying beneficiaries? coverage and billing for Part D-covered vaccinations. CMS reported that because of changes in beneficiary behavior and the healthcare delivery system, economically, it is not in CMS' and other stakeholders' best interest to develop an alternative reimbursement process for physician administered Part D covered vaccinations. The agency noted, however, that it will continue to encourage both physicians and beneficiaries of the health benefits of recommended vaccinations.

Full Report

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BeneficiariesPhysiciansProgram beneficiariesMedicareVaccinationAdultsPrescription drugsCorporate stakeholdersTetanusInsurance coverage