August 13, 2015
2 min read

Recommended vaccine coverages could cause monetary losses for HIV clinics

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Due to wide variation in immunization reimbursement, the administration of recommended vaccines to appropriate candidates at urban HIV clinics could result in potential net losses of $100,000 annually for each clinic, according to recent findings.

In the study, Michael S. Saag, MD, of the University of Alabama at Birmingham, and colleagues investigated the estimated cost of vaccinating 2,887 eligible patients with Gardasil, Prevnar and Zostavax at a U.S. Ryan White Part C academically affiliated HIV clinic in Alabama in 2013. The researchers calculated the clinic’s expenses using vaccine price and administrative fees, and determined revenue using insurance reimbursement data for vaccination. Insurance status was stratified as Medicaid, Medicare, commercial insurance and uninsured.

The analysis accounted for the three-dose series of Gardasil (Merck) and single doses of Prevnar (Pfizer) and Zostavax (Merck). The researchers calculated these expenditures and revenues for 100% uptake of vaccine, adjusted uptake based on published rates and adjusted reimbursement based on insurance status before the Affordable Care Act (ACA).

The researchers collected the reimbursement per dose across insurers, computed the mean, median and maximum reimbursement paid for each vaccine and the net yield.

Of the 2,887 included patients, 27% were on Medicare, 13% were on Alabama Medicaid, 26% were on commercial insurance, and 34% were uninsured.

Significant disparities in reimbursement existed for each vaccine based on insurance time identified by the researchers. For example, Medicare did not reimburse the clinic for Gardasil or Zostavax under Medicare Part D, but did cover these vaccines upon presentation by the patient of a prescription for vaccine receipt and administration to certain commercial pharmacies. Similarly, Alabama Medicaid reimbursed for Gardasil only for patients aged younger than 19 years, contrary to Advisory Committee for Immunization Practices (ACIP) recommendations. Conversely, commercial insurers reimbursed as much as $166.44 per dose of Gardasil and $210.32 per dose of Zostavax.

Michael Saag

Michael S. Saag

In calculating the net yield for each vaccine among the total clinic population using a base-case scenario, the researchers found that Prevnar was the most costly of the vaccines (mean net loss, $60,691). Because 60% of patients eligible for Prevnar were vaccinated through Blue Cross/Blue Shield, the significant losses associated with Prevnar were attributed to differences in pricing ($150.20 per dose) and reimbursement by commercial insurers ($138.69 per dose).

Still more significant in terms of cost were losses incurred through vaccine administration. Commercial insurance covered approximately half of the fee for vaccine administration, resulting in a loss of nearly $24 per patient in administration fees alone. This would mean that administration of all three vaccines to eligible patients in 1 year would result in a net loss of $97,122, and an annual clinic loss of $48,918, adjusted for decreased vaccine.

By using pre-ACA reimbursement for vaccination of uninsured patients, the researchers found that clinic losses were reduced to $62,326. This reduction was the result of reimbursement through Ryan White funds.

“This study identifies key clinical and financial issues faced by medical clinics,” the researchers wrote, saying additional studies are warranted. “It also raises questions facing HIV medical providers and health systems as they strive to optimize care and navigate successfully in the rapidly changing post-ACA financial reimbursement environment.” – by Jen Byrne

Disclosure : Eaton reports receiving funding from a Bristol Myers Squibb virology fellows research training program and from the UAB National Research Services Award Fellowship in Health Services, Outcomes, and Effectiveness Research supported by the Agency for Healthcare Research and Quality. Please see the full study for a list of all other authors’ relevant financial disclosures.