Healthy Aging and Immunizations

Healthy Aging and Immunizations
Russell Senate Office Building, Room 385
Friday, February 23, 2018

10:00 – 10:10 a.m. Welcome and Introductions
 Sarah Dash, MPH @AllHealthPolicy
Alliance for Health Policy
 Laura Hanen, MPP @AVACNow
Co-chair, Adult Vaccine Access Coalition
10:10 – 10:45 a.m. Presentations
 Wilbur H. Chen, MD, MS, FACP, FIDSA
University of Maryland School of Medicine
 Litjen (L.J) Tan, MS, PhD @lj_tan
Immunization Action Coalition
 Charley John, PharmD
Walgreen Co.
 Robert H. Hopkins, Jr., MD
University of Arkansas for Medical Sciences

10:45 – 11:30 a.m. Question and Answer Session

Please note: this is an unedited transcript.

SARAH DASH:  Well, thank you. Good morning everyone. So my timer went off, so it means it’s time to start. I am Sarah Dash. I’m President and CEO of the Alliance for Health Policy and on behalf of our board and our staff, I want to welcome everybody here this morning for today’s briefing on Healthy Aging and Immunizations. And for those of you who may not be familiar with the Alliance, we are a nonpartisan organization dedicated to advancing knowledge and understanding of health policy issues. And I’m particularly excited about today’s briefing because we’re going to be learning about how evidence, scientific evidence, is really translated into real life practice as we talk about vaccines, and so we’re going to be learning a lot more about that.

We’re going to be live Tweeting during the briefing, so if you would like to, you can join the conversation on Twitter at #Allhealthlive. Just a quick note on a totally different topic, but the Alliance will be back on the Hill this coming Monday, February 26th, at noon for our lunch time briefing on Medicaid Long-term Services and Support. So, for those who want to continue with the aging theme, you can join us on Monday.

A little bit about today’s topic. I mean, it may be news to some of us that we still need vaccinations over age 18. I kind of knew it, but once we started going into the details of this briefing, I didn’t realize quite the extent of it. And, yet, despite high rates of childhood vaccination, rates of adult vaccination remain very low. So today we’re going to learn more about the science behind why vaccines are still important for adults, what the health outcomes and consequences are when people are not vaccinated, and particularly, then, we’ll hear about coverage, access, and how all of that translates into health outcomes.

So before we get started, I would like to thank the Adult Vaccine Access Coalition through a grant from GlaxoSmithKline for making today’s briefing possible, and I am going to briefly turn it over to Laura Hannon, who is co-chair of AVAC for some brief remarks, and then I’ll be introducing our panelists. Thanks.

LAURA HANEN:  Thank you so much, Sarah. Good morning everyone. I hope you’ve had a chance to get some coffee and some bagels. Thank you for joining us on this quasi-dreary Friday morning for a really important topic, which is Healthy Aging and Immunization.

So, as was said previously, I am the co-chair of the Adult Vaccine Access Coalition. I also work for the National Association of County and City Health Officials, and immunization is critically important for the 3,000 local health officials around the country.

So, again, thank you for joining us. I think this is going to be a highly educational and interactive briefing. I’m just going to tell you a little bit about AVAC. So AVAC is a coalition made up of over 50 organizations that have come together to address adult vaccine access, and this includes representatives of public health, like myself, healthcare providers, pharmacists, patients, and consumer organizations, and innovators in the field. So we are quite a diverse group of folks, but this is such a high priority for all of us that we want to make some progress increasing access and increasing rates of adult immunization in this country.

So our coalition is committed to building awareness and improving access, as I said, to adult vaccine, and we’re just pleased for the opportunity to sponsor this briefing. So I just want to give a few remarks before I hand it over to our wonderful panel. So vaccines, they’re, as you know, are remarkably effective in preventing illness and reducing hospitalizations. Over the past 50 years, we’ve made incredible success in terms of pediatric vaccine and high rates of vaccination among the children in our country, but we still have a long way to go in terms of adults. And there’s a variety of reasons why we still have a long way to go, but I’ll talk a little more about that.

We’ve been very successful in terms of having vaccines available and reducing or eliminating dangerous and deadly infectious diseases in terms of polio, measles, rubella, pertussis, and chicken pox. But despite the success, we still have a long way with protecting adults. So we have more than 50,000 adults who are dying on an annual basis, approximately, from vaccine-preventable diseases, and many more – millions, in fact, are suffering from entirely preventable illnesses. They’re missing work, they have an inability to care for their family members, and some of them have debilitating health effects as a result of those diseases, so obviously we can be doing more. What are some of the barriers? Some of the barriers are just straight up, patient education, so that folks know which vaccines they should be getting. Then there’s a vaccine schedule that is sometimes a little bit confusing, not always clear which ones you should be getting and when. Then the availability of vaccines from various providers, from our vaccine neighborhood, as well as financial barriers and reimbursement barriers for our providers in terms of being – for them to be properly reimbursed for the vaccines they’re administering.

So what are AVAC’s priorities? We have three. One is related to strengthening the vaccine infrastructure, and what I mean by that is, we want to improve reporting. We want to improve that through the immunization information systems that we have in the states around the country. We also want to improve the connection between the immunization information systems with all of the health information technology and health records so that we actually know who’s being immunized where and when so we can pull up records and see what people have been immunized for. In addition, we want to reduce barriers, like I said, to access and increase those rates for adults. We also want to increase our measurability so we all know what measure gets done. So having appropriate measures for adult vaccine will go a long way for ensuring that we know how well we’re doing and we can also be prompting our providers in our vaccine neighborhood to actually immunize our adults.

So, with that, I just thank you once again for being here this morning, and I am going to turn it over to our panelists.

SARAH DASH:  Great. Thank you so much, Laura. So I’m going to briefly introduce our panelists. Their bios are in your packets, their more lengthy bios, but we have a really incredible panel of experts joining us today. First I’m going to introduce them in speaking order. To my left, to your right, I have Dr. Wilbur Chen, who is an Associate Professor of Medicine and Chief of the Adult Clinical Studies Section at the Center for Vaccine Development at the University of Maryland School of Medicine. Dr. Chen also heads the University of Maryland Travel Medicine Practice, so if you feel like you need to take a trip he might be able to answer your questions afterwards. He received his MD from Howard University and completed his residency in internal medicine at Johns Hopkins Bayview, and a Fellowship in Infectious Disease at University of Maryland, and has numerous other distinctions and awards. So thank you for joining us, Dr. Chen.

We’ll next hear from Dr. L.J. Tan. Dr. Tan is Chief Strategy Officer of the Immunization Action Coalition, co-chair and co-founder of the National Adult and Influenza Immunization Summit, and former President of the Board of the Adult Vaccine Access Coalition. His current appointments include serving as Special Consultant for the European Union Influenza Summit and the Asia-Pacific Influenza Summit, and AMGA’s Adult Immunization Collaborative, to name a few. Dr. Tan received his Master of Science in Biology at NYU and a PhD in Microbiology and Immunology from Northwestern University. All these people can give you great career advice, too, by the way.

Next we’ll hear from Charley John. Charley serves as Director of U.S. Public Policy for the Walgreen Company. He has been with Walgreens for 20 years, 14 of them as a practicing pharmacist and he earned his Doctorate of Pharmacy from the University of Florida. So, welcome, Charley. Thank you.

Finally, we will hear from Dr. Robert Hopkins, Jr., who is a Professor of Internal Medicine and Pediatrics, and serves as Director of the Division of General Internal Medicine, and Associate Program Director for the Internal Medicine Pediatrics Combined Residency at the University of Arkansas School for Medical Sciences. Dr. Hopkins is past governor of the Arkansas chapter of the American College of Physicians, and he’s board certified in internal medicine and pediatrics, and maintains an active teaching and clinical practice, caring for both adults and children.

So thank you all very much for joining us, and with that, I’m going to turn it over to Dr. Chen to start off the presentations, and then we’ll have a Q&A section. Thank you. And, if you just – if you like, just make sure that the red button is on so that we can hear you. Thank you.

1. WILBUR CHEN: Okay, can you hear me now? Thanks so much for coming here today. This is really a topic that’s near and dear to my heart. So first, I want to lay the groundwork and try to answer the question why healthy aging might be important.

So if you look at the statistics for the aging of the population here in the U.S. – this is CDC data – you can see these two lines. And what you’re seeing is a line for the 65 and overs, and a line for the 85 and overs. And what you’ll notice is that by 2030 we’ll have 71 million older adults, and I’m defining that by 65 years of age and older, which consists of 20 percent or more of the total population here in the U.S. and that’s expected, in and of itself, to increase healthcare spending by a quarter of what it is right now. By 2050, that’s expected to increase to 90 million and of which the proportion of older adults, which is 85 years and older, will be much higher, 20 million. So we have a growing problem, perhaps, or a growing pleasure because we’re going to have older folks in our population. And this is a consistent trend that you’re going to see globally as well, so it’s not just a phenomenon here in the U.S. I think healthy aging is going to be a very important issue in the decades to come.

So there’s a problem here in that there’s something called immune senescence, which is a scientific term, but what it really means is that, as we age, the immune system ages as well. These effects don’t just happen chronologically. There are a lot of other reasons why there is aging of the immune system, and it could be because of comorbid factors and other things, but in general, we say around age 65 and over, what does it mean? Well, the effects are that you have increased incidents of certain infections. You have poor responses to vaccinations in general, and you have – when you get infected, you have poorer outcomes. So that is an important thing as we think about this aging population.

There are a number of vaccines that are available specifically for the aging, and I’m highlighting three that I’ll cover today, but there are other vaccines that we want to think about to cover this aging population, and there are some vaccines that are also under development that we’ll not discuss today but are important for our research agenda.

Now, influenza is the big thing that, perhaps, people are thinking about these days and so what I’m showing you is this U-shaped curve, which is what we describe, because what you see is the mortality and morbidity, the hospitalizations, medically attended clinics for illness and deaths due to influenza occurs over an age spectrum, and you can see that it’s highest from earliest of childhood out to when people reach about 65 years of age and older, you can see that both in this figure and also in the table as well in the mortality rates. And so what you’ll notice is that approximately 80, and oftentimes, greater than 90 percent of the mortality occurs every year in the older adult population, so this is very important.

There are influenza vaccines, so despite the fact that you hear about these flu vaccines perhaps have less efficacy, no vaccination is far worse than a vaccine that at least has some partial efficacy. So we have a number of vaccines that are available. You’ll see the two last bullets, the high-dose and the adjuvanted vaccines are actually specifically targeted for the older adult population. So this is important perhaps that, if you don’t know, but the preference is there is no preference in vaccination in that we all say that it’s a missed opportunity if you don’t get vaccinated at all.

What do these vaccines do? We know that they can reduce influenza illness, which could be mild, but it could lead to hospitalization and it could lead to death, certainly. We also know that influenza can be associated with bringing on heart attacks and strokes as well. So vaccination serves a number of purposes, especially as we’re thinking about the older adult population.

Now, in 2016, uptake of influenza vaccination among the older adult population was only 67 percent. Our goal for healthy people 2020 is 90 percent, so we’re not close. We’re getting there, but we need to get better, and actually the numbers of uptake have been around 65 percent for many years, so we’re not really making a lot of headway.

Pneumococcal disease is also another important entity where you can see, in the gray lines here – I’m not sure if it projects well – but the incidence for mortality is also that U-shaped, where it’s early on in childhood and then you see this rising incidence as we get older as well, and it starts to increase when we get 65 years of age and older. Hospitalizations also follow for pneumonia, which is one of the common causes of pneumonia is the pneumococcus. So you’ll notice that there’s a higher incidence among older adults. The majority of the case fatalities occur among older adults for this particular pathogen, as well. We have two different vaccines that are available. Both vaccines are to be administered. There are some people that say that it’s a little bit confusing and that’s because the recommendations by the ACIP have changed over the past few years, but I think that, in essence, the recommendations are easy to implement if you understand the basic underlying philosophy behind it. And the reason for vaccination is because we want to reduce that mortality, this invasive disease that’s associated with it, as well as pneumonia. Uptake in 2016 was only 20 percent for this particular vaccine, and again, our goal is to have 90 percent of the population. I think our goal should be better we should aspire to 100 percent but, again, we’re only at 20 percent here. So I think that this, again, raises the specter for us to have room for improvement.

Shingles, I don’t know if any of you have ever had shingles, but it can be very painful. It’s not just a rash. The rash is actually the mildest part of the disease, but it’s the postherpetic neuralgia, which I’m highlighting here, which is the most detrimental part of this infection. There are more than 300,000 cases per year, but you can see that the rising incidence of shingles, and in the darker bars is where there’s postherpetic neuralgia where there’s about 50 percent of people who experience shingles will have postherpetic neuralgia, which is a debilitating painful disease that can occur for months at a time, so it is very debilitating. We have two vaccines that are available and, in fact, the newest vaccine was just approved last year and there is actually a preference. And why is there a preference? Well, it’s based on this really tantalizing data that’s coming out right now with really high efficacies with this so-called subunit vaccine. The purpose of the vaccine is to reduce the shingles, the rash itself, but also the postherpetic neuralgia, also the duration of this infection and the time for healing. So these are all important factors, as well. Unfortunately, uptake of these vaccines is only 30 percent. We’re hoping, with this newer vaccine, which has incredible efficacy, that this will increase as well, but this is also room for improvement.

There are a number of resources that I’ll point you to. I’m just showing you a couple here from the National Foundation for Infectious Diseases, but there are a number of sources, perhaps in your packets as well, that you can look at today. But my summary is that we, in general, want to raise awareness that there are vaccines that are available specifically for the elderly. We have a lot of room for improvement for uptake of these vaccines. We need to perhaps think about a research agenda to create better vaccines, to perhaps implement these vaccines better. This is not something that’s just a U.S. phenomenon. There is actually a global call for immunization across the lifespan, which means recognizing from birth all the way to death. The upper age spectrum, we need to also address with specific immunizations as well. And we certainly don’t want to discourage pediatric immunization because we understand that there are a lot of indirect effects, which means that when you immunize a child, that you also end up inadvertently immunizing the older adults, which might be the grandparents or other caregivers, as well. This is called Community Protection. It’s called Herd Protection in other terms, but these are all very powerful effects as well, so it’s a very holistic way of addressing it.

I think that that’s all I had to say. Thank you very much.

[Applause]

SARAH DASH:  Thank you. Alright, Dr. Tan.

1. L.J. TAN: Thank you, Dr. Chen, for handing that over to me, because I think my next probably will following right away from you.

Looking at the Healthy People 2020 goals for the shingles vaccinations, he showed that for 90 percent for influenza. The goal for 2020 is 30 percent, so we actually hit our Healthy People 2020 goals. But you know what I like to say when people tell me that? I say, when all else fails, lower your standards. [Laughter]

But now, I’m going to turn it over and talk a little bit about, you know, the coverage issue because you heard Laura talk about the fact that one of the challenges we have with getting people vaccinated is actually a lot of patients don’t want to be out of pocket. They don’t want to have to necessarily pay for vaccines, and the cost of adult vaccines sometimes is a barrier for both providers giving it as well as patients getting vaccines. So I’m going to actually quickly talk about the coverage issues that we see with payment and reimbursement from both the patient perspective as well as from the provider perspective.

A quick disclaimer: these are my opinions, not necessarily those of my employer or the Summit that I co-chair, and I’m going to start with this, and this is actually the cost burden of four adult vaccine-preventable diseases in the United States. This follows up on Dr. Chen’s presentation, so if the morbidity and the mortality that these diseases cause our public doesn’t bother you, I’m going to say maybe the $15 billion cost, annual cost for these diseases will. So hopefully, it’s the mortality and the morbidity, but if not, hopefully the cost will drive you along. And that’s the cost for just 65 and older, for these four adult vaccine-preventable diseases. Now, if you throw in the 50 to 64 population, you can add another $11 billion annually to that tab. So, acknowledging that vaccination is never 100 percent, acknowledging our access and our cover rates are very poor, if we can improve those rates just a little bit, can you imagine the dent we would make in terms of that cost to our healthcare system? So it’s something to think about.

So I’m going to quickly do a quick primer on who pays for vaccines in the United States, and I’m not going to focus too much on this because it’s a lot of detail. All of you are probably aware of the Vaccines for Children program. That provides – it’s an entitlement program that provides free vaccine for uninsured children up to the age of 19 in Medicaid, as well as American Indians and Alaskan Natives. And, if you’re an underinsured child, in other words, you have insurance but your insurance does not pay for vaccinations, you can get covered by the Vaccines For Children program in the federally qualified health clinics.

The one I’m going to quickly spend a little bit more time on is Section 317, and Section 317 is an annual appropriations program and actually it is fundamental to not just immunizations for older adults and adults, but also for children as well, because it is the major funding source for our immunization infrastructure in the United States. If that infrastructure goes away, we will not be able to get vaccines into the arms of people. We can have all the vaccines we want, but a vaccine is useless unless it gets into the arms of our patients, and so that’s kind of where a lot of that funding goes. And, unfortunately, it’s been stagnant for a long time, so that’s one of the big programs; it’s an annual appropriations process that we keep focusing on because that funds our infrastructure.

Obviously, our 65 and older Medicare is a big deal. It covers vaccines for those 65 and older: flu, pneumo, and hepatitis B are covered under the Part B of Medicare, and then all other vaccines are covered under Part D, as in dog. So, for example, the shingles vaccine that Dr. Chen mentioned, it’s covered under Medicare Part D.

Then finally, I’m going to just end here and talk about the private sector. In the private sector, what’s really interesting is that the way vaccines get paid is that the price of the vaccine gets negotiated between the provider and the distributors and the manufacturers of the vaccine. The payment that the provider receives is negotiated with the payers. So you pay, you get paid, but, for providers giving vaccines, you do not get paid the way you do for pharmaceuticals. With pharmaceuticals you write a prescription, the patient takes it to a pharmacy and gets their drug. For vaccines, you give the vaccines and then it’s the provider’s responsibility to get paid for that, so that can create a challenge for our providers as we go forward. So this is who pays for vaccines.

Just to remind people, the Affordable Care Act has mandated that all ACIP recommended vaccines are to be provided to patients at no cost sharing.

SARAH DASH:  And what’s the ACIP?

1. TAN: Oh. Just to mention that that. The Advisory Committee on Immunization Practices, so that’s the federal Advisory Committee of experts that provides guidance and recommendations to the CDC that ultimately result in our vaccine recommendations in the United States. Thank you, Sarah. I appreciate that. And ACA, Affordable Care Act. Those acronyms will get us all. [Laughter]

One thing to keep in mind is that the ACA requirements for paying vaccines at no cost sharing to the patient, is only for an in-network provider, and I’m going to come back and touch on that very quickly in a few minutes.

Just to remind folks that the ACA also extended its mandates for coverage to all ERISA plans, so all those self-insured ERISA group health plans are now also required to cover all those advisory committee recommended vaccines as well at no cost sharing to the patient. This is important because, as I said earlier, and as Laura mentioned earlier, the cost to the patient was a significant barrier for vaccine access for a lot of our patients. They didn’t want to have to pay to get vaccinated. This actually, now, made it such that if you had insurance you would get covered. Because of that, the National Vaccine Advisory Committee that advises HHS issued a National Standards for adult immunization practice, which is what you see here. I’m not going to run through this, but this basically highlights the fact that we recognized that there was a challenge with adult immunizations, and what we basically called on all adult providers of health was that they had to do four things. They had to assess their patients’ status for vaccination; they had to educate that patient and recommend the vaccine; they should vaccinate the patient, but if they don’t vaccinate they should refer that patient, and that’s when I’ll turn it over to Charley in a few minutes; and then, they should document receipt of that vaccine. That being said, while we’ve created this position where patients can now get vaccines for free if you’ve got insurance, there are still some challenges and gaps that have resulted from the process of trying to cover that. For example, for private insurance, there are differences that exist between what is an FDA indication for a vaccine versus what is an ACIP recommendation. For example, the shingles vaccine that Dr. Chen mentioned, the new one, is recommended or indicated by the FDA for ages 50 and above and there is no exclusion, for example, for immunocompromised populations. However, the ACIP recommendation that just passed has not addressed that immunocompromised population, so if a physician provides vaccination to, let’s say, someone who’s 55 years old who is immunocompromised, will the Affordable Care Act mandate cover that vaccine? Currently – no. So that physician is going to be out of pocket. Now the ACIP will probably address this in the near future, but those are the challenges that our providers on the ground face when they’re trying to get paid for vaccines and when their patients are trying to obviously secure those vaccines, as well.

This is the issue I brought up earlier. If you are out of network; so, in other words, if you are a provider that’s out of network for the payer, the ACA mandates for coverage at no cost sharing don’t apply, and that creates a problem for a lot of our pharmacy immunizers, because most of our pharmacy – all of our pharmacy immunizers are out of network. So I bring that up because I think that’s an issue of access that you will hear a little bit about going down the panel here.

Medicaid Expansion, while phenomenal and great for the states that expanded Medicaid has created a huge disparity of coverage differences among all our different states. So if you’re an expended Medicaid state, you can cover vaccines. If you expanded Medicaid you’re required to cover vaccines at no cost sharing; however, you can also choose to ignore coverage for the traditional Medicaid population. That means those before 2014, so in those cases you could have an expanded Medicaid state that has benefits for those who have expanded and no benefits for those who are on traditional Medicaid. And then, if you have not expanded Medicaid then you have no coverage whatsoever for your patients, for adult patients.

I think there’s a lot of disparities that are out there for coverage gaps with Medicaid and I think that’s something that we probably will have to address going forward because of this big problem, which is our uninsured populations. Remind everybody, we have 30 million adults who remain uninsured, and this number will increase in the next few years and, unlike the children where we have the Vaccines for Children program that covers uninsured children, we don’t have such a program for our adults and so this public health safety net will become extremely important.

I mentioned this, and I’m going to say this is a challenge for our providers on the ground. There are differences in the way in which vaccines are covered under Medicare Part B, as in boy, and Medicare Part D, as in dog. Medicaid Part B, in boy, is actually a program that actually works really, really well for a lot of our providers, but when you look at Medicare Part D, as in dog, it creates challenges. The GAO has actually issued a study on this and pointed out that there are problems with access when you cover adult vaccines under Medicare Part D. I’m not going to go into a lot of detail because I believe that report is available to you, but this is something that we continue to wrestle with as we go forward.

I’m going to wrap up by saying this final point: while the Affordable Care Act and a lot of the work we’ve done have actually relieved the cost burden to our patients – and it actually also has relieved the fact that we now get provider payments so our providers get paid for giving vaccines – one of the things that has not relieved is this issue of the adequacy of provider payment. In your packet, you’ll see three more slides that I’m not going to go through here, that talk about the cost that is faced by our providers as they go forward trying to give adult vaccines. The one thing I’m going to mention and this is the fundamental difference between pediatric practice and adult practice is the final bullet on the bottom of this slide. Adult vaccine providers do not have the same economies of scale that a pediatric provider has. A pediatric provider is providing thousands and thousands and thousands of vaccines in a month, because you’ve got the 2-, 4-, 6-month schedule. For those of you have kids, you are aware of that. For the adults, you’re talking flu once a year, Tdap once every 10 years, actually TD once every 10 years, Tdap just once, right? So there’s not that bulk of business for an adult provider, so that creates differences in which the adult provider has to be reimbursed in order for them to stay in business. It’s something that’s very important, and something I think Dr. Hopkins will also take a look at.

And so, to wrap up, I know I’m over time, but I have to talk about this because we hear so much about influenza right now. This is this idea, kind of following up on Dr. Chen’s point, is this idea that we hear so much about vaccine effectiveness for flu. We hear about 36 percent effective for all flu, 26 percent effective against H3N2, and I want to point out that that’s not the most important thing about flu vaccine. And, in fact, it’s probably not the most important thing about all adult vaccines, and that’s this idea that those effectiveness numbers deal with incidents of disease. In other words, what they say is that if you get vaccinated you have a 26 percent chance of not getting infected with the disease. What it does not reflect is this component, and this component is that when you get vaccinated and, if you still get sick, you will do far, far better than if you did not get vaccinated. And what we’re talking about is this whole concept that if you get sick with influenza, and you talk to any 65-year-old and you ask them, or 70-year-old, what worries you most as you get older, it’s not dying. It’s actually, the first thing they’ll say to me is, “LJ, will I be able to go home and cook?” “LJ, will I be able to walk out of the hospital bed?” And I will tell you, if you don’t get vaccinated and you get influenza you will walk into your hospital bed, but you will come out with a walker and those things matter to the aging population and sometimes we lose that when we talk only about incidents of vaccine effectiveness. So I would like to say, to wrap up here, when you talk to folks about influenza vaccination I think you should say, “Are you willing to risk your independence this winter by not getting vaccinated?”

So thank you very much. I appreciate you giving me a couple of extra minutes there.

SARAH DASH:  Thank you.

[Applause]

Dr. Tan, thank you for making those points about the added disability and I think perhaps, you know, as we talk about Medicaid and Medicare and as those of you think about those programs and kind of the downstream effects, this is obviously all interconnected, so thanks.

So now I’m going to turn it over to Charley John who is going to give his presentation from the podium.

CHARLEY JOHN: Sorry, I’m breaking the rules a little bit. I decided to get up; I couldn’t see the screen from back there. Thank you, Dr. Chen, and Dr. Tan, and look forward to Dr. Hopkins’ remarks. There are some very powerful messages. And, in watching the presentations, I’d maybe like to kick it off with a story.

Before I was in my current role, in the public policy role, I served as a pharmacist for our company, so let me take you back about seven years ago. A patient had come up to my counter and inquired about a few folks that were waiting in line off to the side of the pharmacy. So my technician had explained t her that we were providing flu shots that day, as we kind of do every day. That day, knowing the demand, what the demand would be like, I decided that we run our services as more of a clinic style and this was so that we could address as many people as possible and kind of also keep it away from people picking up their regular prescriptions. So she decided to wait in line and when her turn came up, she came to me and she said, “Well, I hadn’t even – it wasn’t on my mind and I didn’t take any time to make an appointment to get a flu shot, but since I’m here and I can do it right away, I’m going to go ahead and get it done.” So we were that close to her deciding to skip out on her flu shot that year, and that’s a pretty typical story. So I’m just getting started with this. As we sat down and started discussing and reviewing her immunization history, we discovered that she was also not current on her pneumonia, her shingles, or her Tdap vaccine. She had not gotten her second dose of pneumo. She had never got her shingles shot, and this soon-to-be grandmother could not remember if she – if and when she got her Tdap vaccine. So I need to convey that we were able to kind of get that all done at once. Now, back then, we did space some of these vaccines out, so technically it didn’t all happen right there, but for all intents and purposes, in one fell swoop, we were able to protect her against those four diseases. So I’m thinking about Dr. Tan’s chart and those four diseases and what it cost to the healthcare system. Those were the four exact diseases that I protected her against in one fell swoop. So I think about that dent into $16 billion or $26 billion that you mentioned, and I hope that you can get an appreciation of the value and the impact that pharmacists can make on immunization rates. This was just one patient on one day in one store.

So if you can just imagine the impact that pharmacists can make if they are more fully embedded in the immunization team, and I think that’s an important concept that was alluded to earlier, and at Walgreens, we fully endorse the concept of the immunization neighborhood, and this is, basically, all providers and all systems communicating, documenting, sharing best practices, measuring quality, basically building off of each other so that we achieve a supreme goal of immunizing as many people as possible. I think it’s an important concept that, among the immunization neighborhood, we all need to adhere to.

I’ll be quick here. Many of you are probably familiar with your pharmacist and their role in dispensing medications. You’ve probably gone to a pharmacy to receive an antibiotic, or a different medication, they dispense that to you. Back when I started, what did you call, 14 years ago, it’s a long time now, that’s mostly what we did. But today it’s really just the tip of the iceberg in terms of services that pharmacists perform that address public health, and high among them is immunization. I can even say that it’s probably the service that we’re most recognized for beyond dispensing. So pharmacists, a little bit about what their capabilities are in this space. They have tremendous education and training when it comes to vaccines, including immunology, administration techniques, safety, and emergency management. There are also tools in place so that the quality around vaccine selection and contraindications are also managed. And, additionally, many companies, like ours and many others, will go to great lengths to make sure that there are resources, not only clinical, but strategies to help our pharmacists improve immunization rates, and it includes collaborating with physicians, community-level engagement, and participation in coalition activities, like that of AVAC, so that we meet those goals, and this all helps our pharmacists to effectively operate and execute on an immunization program. So, at the end of the day, we are providing the right vaccine to the right patient at the right time.

Now the first time I administered immunizations to my patients was back in 2008. We did it on only one day and, that day, I gave 12 people their shot. Twelve. And you can characterize this as pretty much the case at most pharmacies back in 2008. The origins of pharmacist involvement in immunizations goes back well over 20 years, but it really has been these last ten years where it’s been more widespread within the pharmacy community. Pharmacist authority, particularly around flu, expanded around that time, so that’s when we were able to get involved. So again, 12. So we came back and took those limited learnings from that time. We created more of an outreach and execution plan. We partnered with entities like HHS on the community immunization program, and the very next year we provided 5 million patients with their flu shot. So we went from a few hundred thousand the year before to 5 million. So our company has come a very long way, but for all of pharmacy, the results are undeniable in terms of the impact that pharmacists can make to improving vaccination rates.

The pharmacy setting has distinct advantages to patients seeking immunizations. Ninety-four percent of Americans live within five miles of a community pharmacy, so there’s access for you. Most are open beyond hours of traditional immunization settings, so there’s convenience for you. We had found out that, among all of our patients that received vaccinations with us, a third of them received them off hours, after 5, on the weekends. So you can imagine that those folks probably would have foregone their vaccine if they didn’t have that extra access point.

I think the results overall are pretty staggering. We see a very significant improvement in rates with the pharmacist being involved. A pilot program known as Project Impact Immunizations, it demonstrated how community pharmacists were able to improve vaccination rates by over 40 percent by getting involved. Here’s a few other results that I have on the screen, it’s gleaned from a recent analysis that was done that reviewed the impact of pharmacist immunization authority on rates, and it compared 2003 to 2013. So basically, this is reflecting on a time when very few pharmacies provided immunizations to a time where it as nearly ubiquitous. And to see the millions more people that were immunized as a result of that, I think it illustrates the impact.

I’ll part with a few areas to lessen the barriers for patients seeking immunizations and the policy areas that can maybe address that. We’re in a period of high drug prices and vaccines can also have that effect. We conducted a study amongst our patients. Patients came in, we educated them or they inquired about getting a vaccine, and they decided that they were probably going to get it, and after we went through the process, at the end of the day, they actually decided to walk away from getting that vaccine. And what we found out is the number one predictor of their abandonment was the out-of-pocket cost. So we don’t want that to be the narrative because, in the end, it’s going to cost us a lot more, so we are supportive of policies that can lower the out-of-pocket cost for vaccines. Also, eliminating any holes in Medicare coverage for vaccines at pharmacies, and Dr. Tan was just alluding to that. You don’t want to be in a situation where a patient comes to your pharmacy, you educate them on a vaccine, and they’re ready to get it, they say, “I’m ready to get it done today,” and then you have to say, “Oh, well, wait. I can’t do that for you right now because it’s not covered under your plan.” You can bet that that lessens the chance that that person is eventually going to get vaccinated.

A couple of other priority areas are there. For sake of time I’ll just speed quickly through that. An area where we are looking to improve adult vaccination rates is amongst our veterans, and authorization of a VA immunization program can really go a long way there. And I think this last year has really given us a look at how disastrous national emergencies can be from California to Houston to PR to the current flu outbreak, an improvement in emergency response and execution is needed. And many times this involves providing vaccines to a large group of people with very limited time to do it, so I think equipping pharmacists with the authority to be able to respond in those situations will really improve our results.

I do feel that the infrastructure is in place for us to make a difference around adult immunizations working with the disciplines that are represented here and the public health systems there is a great foundation for us to make an impact on adult vaccination rates. I’ll quickly point out, I’m reminded by – it’s the Bill and Melinda Gates Foundation, in their annual letter last year, I distinctly remember them remarking, saying: “Vaccines are the best deals that we have.” I think it’s a very strong message, so we know that these work. They save countless lives. They save billions of dollars, but we just need to get people to use them, so I think we need to use all approaches and resources to achieve that. Thank you.

[Applause]

SARAH DASH:  And before we hear from Dr. Hopkins, I just want to kind of tie together a couple things. Dr. Chen, you mentioned immunizing children can help kind of with the Herd Immunity for adults, and then Charley, you mentioned that the woman who came in and you made sure she had the Tdap vaccine, which is the tetanus-diphtheria-pertussis, grandmother-to-be, presumably, right, because that protects – and personally, as a pregnant woman, I now know that Tdap is very important because, right, the child will get pertussis otherwise or increases the risk, right? So I should let the experts talk, but just to point out to go either way. Alright, so now we’ll hear from Dr. Hopkins. Thanks.

1. ROBERT HOPKINS: So, a critically important point that you make, though, is, you know, where I want to start off and I apologize for all the words on my slides, but we’ve talked a lot about individual benefits from vaccines and that’s absolutely critical, but we can’t forget that we’re also aiming for benefit beyond the individual when we talk about vaccinating adults, as well as children.

There’s a concept out there that many of you may have heard of called Herd Immunity. I prefer the newer modification of the term “community immunity,” because we’re humans, we’re not cattle. [Laughter] The reason that this is important is, when each of us gets a vaccine in our arm, we get benefit for ourselves. We get benefit within our home for those that are in our family that we may not give the vaccine-preventable illness to. We also, if we have enough of us vaccinated in our workplace, may prevent workplace illness. If we have enough vaccinated within our community, we may also protect those in our community from illness. So, community immunity is a concept that, if we vaccinate a large proportion of people in our community, we reduce the overall incidence of that disease in the community, and that’s the second critical point that we have to remember about vaccination. But, if there are segments of your population, maybe a cul-de-sac that people are not well vaccinated and somebody gets exposed, that community immunity is not going to provide effective protection when you have a group that may object to vaccines or not get vaccinated. So community immunity is a concept that’s important, but we need to get vaccination throughout our community and we need to get through these ideas about vaccine objection or vaccine hesitancy that can also adversely affect our population.

So what is this concept of vaccine hesitancy? Well, we’ve had people that have been hesitant or objecting to vaccines going back to when Edward Jenner first started using small pox vaccine in the 17th century. This trend has gone up and down over the years. There are lots of reasons why people might object or not get vaccinated. I’ve outlined a couple of things here, but really it boils down to all of us: the community, those in government, those in public health, those in healthcare—pharmacists, physicians, and others need to make sure that we all have the same set of messages about vaccine value, about vaccine safety, and about vaccine benefits to individuals and communities, not only prevention of disease but reduction of disability and reduction in spread to others within our communities—all important for us to remember when it comes to vaccination and protection of our communities.

Now we talked a little bit, in some of our earlier presentations from Dr. Tan about this vaccine supply process. I’ve kind of outlined graphically how the vaccine process may work in a physician’s office. This could be similarly represented for a community pharmacy. The vaccine has to be purchased. You have to make sure you store that vaccine appropriately, whether it’s refrigerated or frozen depends on the particular vaccine. You have to have a commercial unit with temperature monitoring. You have to have an uninterruptible power supply so that you don’t have that power go out in your office; the vaccines are spoiled, now you’ve wasted all that money you’ve invested on vaccines. If something happens that you waste vaccine that’s an X. That’s vaccine loss. That’s money lost in a practice or in the pharmacy. You have to vaccinate the patient and you have to make sure you get the right vaccine into the right arm at the right time. You need to document that vaccination. If you don’t document it, it potentially is seen as it didn’t happen because the patient may not remember whether they’ve gotten that particular vaccine, particularly if it’s a one-time vaccine or a vaccine you might get every 10 years. Hopefully we’re going to remember the flu vaccine that you’ve had this year.

Finally, you need to bill for it, and you need to get paid for the vaccine.

All of the X’s in this diagram indicate places that the practice can lose money because they haven’t taken care of all of those steps, so if you do all of these things correctly and you vaccinate your patients who have insurance that covers for those vaccines, you potentially can break even or even make a dollar or two vaccinating in your office. The problem is, for our seniors, many vaccines, Tdap and shingles being the most important, are covered by Medicare Part D. Medicare Part D does not pay physicians for anything. Medicare Part D is a pharmacy benefit plan, so if a Part D vaccine is given by a pharmacy that is a participating pharmacy in that plan, it gets reimbursed. Won’t happen if it comes into my office, so for me to be able to give a Part D vaccine in my office, I have to have a collaboration with a pharmacy that they either give the vaccine when I send a prescription over, or they give the vaccine and send me documentation back so I can record that in my record. There are lots of holes in this system. We might call it a collaborative rather than a system.

The last part of my talk is basically just to give you a bit of a feel for what are the important issues that a practicing physician in an office, in a hospital, those of us living in the community or in a nursing home might think about regarding vaccines. So you see here, increasing provider vaccination, vaccination of everybody within the office setting, is a first important step that probably doesn’t happen as consistently as it ought to. Many organizations, including the American College of Physicians and the American Academy of Pediatrics that I’m a member of, have a policy that all healthcare providers within that group should get vaccinated. Many hospitals across this country apply to the standard of the Joint Commission that all healthcare providers within that hospital system should be vaccinated, but there are many small offices where that may not happen. So if you don’t have everybody in the office vaccinated, there’s the potential for spread of disease, influenza as an example, within the office. So my first slide is, we have to think about vaccination of the providers in the office because if you talk the talk and you’re not walking the walk you’re less likely to vaccinate your patients effectively.

My second point is thinking about, in the office setting, how are we going to make sure that we vaccinate our patients? It goes back to that flow diagram I had up earlier. You have to have vaccine available, you have to have buy-in with the team, you have to make sure that you appropriately vaccinate your patients, you document it, and you make sure that you continue that process in a longstanding way. Next is in the hospital setting. I hope none of you have been in the hospital, or your family members haven’t been, but in realism, we recognize that many have. In the hospital, as you all know, lots of things are going on at one time. It is important that anybody that’s hospitalized during flu season get a flu vaccine if they haven’t already had it that season. It’s important that anybody with chronic illness that’s in the hospital get a pneumococcal vaccine. Oftentimes those things don’t happen because all of the other things going on in the hospital get in the way, so to speak. We’re taking care of that pneumonia, or taking care of that infected foot ulcer, so having a policy and standing orders in place to help that happen is going to be very important in a hospital setting. In long-term care, unfortunately, many of our population are in nursing homes or rehab facilities. There are some states that, by law, require that everybody that works or resides in a long-term care facility be vaccinated. That mandate can help some but that’s not universal, and we don’t necessarily have ways of getting that information when it happens into a registry so that we can know, if a patient leaves that setting, that they’ve been vaccinated. So another set of challenges.

And then, finally, to close, thinking about our communities, we need to make sure that we’re all talking the same talk about the value of vaccine for prevention of disease, for prevention of disability, for protection of the community. Vaccination is critically important and we need to build systems to facilitate that happening for the benefit of all of us in this country. And then, I’ve listed a few resources here for you in the slide set. Thank you very much.

[Applause]

SARAH DASH:  Thank you all for your presentations. They were really informative. And we’re going to go now into an audience Q&A session, so if you have a question feel free to raise your hand, and we have one already.

AUDIENCE MEMBER:  First of all, thank you for this panel. This was wonderful, brief, and very persistent. I’m really delighted. What [inaudible] … or the brochure that you have financial barriers to immunization. I don’t know whether everybody got it, so I want to show this picture. There are not only financial barriers to immunization, but there are also psychological barriers, and if you think about the articles that you read in mainstream media, like [inaudible] … whenever it comes to immunization you see these little tiny cute babies being vaccinated, crying like hell, screaming like hell, and I think that’s an unnecessary psychological barrier. I was delighted to see this happy [inaudible] being vaccinated woman. So if any of you have influence, if you give a talk to – talks to journalists or so, make sure they have the appropriate picture in that article and not, you know, these disastrous – these little kids [inaudible]. [Laughter] Thank you.

SARAH DASH:  Oh, as a mom of one, my son was four years old. He escaped from the pediatrician’s office, not once, not twice, but four times in one visit, and had to come back for his shot, so thank you. But, if any of you want to comment on kind of the communication aspect, go ahead.

1. ROBERT HOPKINS: So, not to plug myself, my Twitter face profile is myself getting the flu vaccine this year. [Laughter] But this – this is critically important, and the other message that I think it’s important for us to recognize is that there are a lot of racial and ethnic disparities in vaccination in our country, and so it’s important not only that we show that vaccination can be given in a non-traumatic fashion, but it’s important that we recognize that we need to vaccinate all segments of our population, regardless of race, creed, origin, language, or whatever other variable you want to pick out.

1. L.J. TAN: I was about to also say, there is efforts to make sure that happens. The National Foundation for Infectious Diseases, every year holds a media conference for flu and pneumococcal, where they actually have – it initiates a campaign that shows all these people getting vaccinated, very happily getting vaccinated, and then it goes out virally and so on social media, so I think you’ve got a really good point. I think part of that, you know, are challenges for, you know, when I was a kid, which is – never mind. [Laughter] You know, they used to tell us it didn’t hurt. And then I think that was the challenge, right? So when physicians tell you that it doesn’t hurt and then it hurts, it undermines the credibility of, you know, what else are you going to tell me about the vaccine? So I think we’ve now realized that and we say, of course it hurts. It’s going to be a pinch, but that’s okay because then think of all the great things you get out of that. So I think it’s – you’re right, it’s about psychologically delivering a message that makes sense and it obviously carries, so thanks.

CHARLEY JOHN:  Just a quick point. I think it’s important to acknowledge that those feelings you have as kids can carry over into adults and that’s what we’re talking about here. Maybe not being scared of the needle, but a lot of the other things that are involved you keep in your mind and that lessens your enthusiasm or interest in getting vaccines. And so I think it’s important, not only as health professionals, but as parents and guardians for these children, to make sure that they understand how important and valuable immunizations are. I have three kids who have been getting their immunizations after the last few years, and I have a similar story that Sarah just described, that they were scared at the beginning. But it is so cool. I’ve been able to tell them about how important it is to stay healthy and be protected by a shot. My kids are actually excited and they stand there and they’re brave and they get their shot. And yeah, it hurt a little bit, but they were so thrilled and I was able to give that message. So that’s just what we need to do as professionals and parents, too.

SARAH DASH:  I’d like to follow up on the point about racial and ethnic disparities, because several of you have made that point and I think it’s an important one. And can you comment on how much of that, and maybe it’s hard to quantify, but it’s due to differences in insurance coverage, insurance rates, etcetera, and can you talk about the trust issue as far as trust in particular communities?

1. ROBERT HOPKINS: I think that there are clear differences in vaccination rates that have been demonstrated from the CDC data in African-American communities, typically vaccination rates are significantly lower than Hispanics. Hispanics are significantly lower than Caucasians. Interestingly, Asian-Americans, in a number of the studies, have higher rates than some of the others. I think there are a number of issues that play into it. Part of it is access to healthcare providers, part of it is coverage related, and there are tremendous differences in trust among different communities. I think there have been many examples where there are reasons for people to lose trust, historically, and I think it’s particularly important that within whatever setting you’re in, whether it’s a pharmacy, whether it’s a community health unit, whether it’s a private practice, whether it’s a hospital that we need to make sure that the whole healthcare team, from the person at the front desk, to the medical assistant, to the nurse, to the doctor, to the office manager, regardless of what their background is, they all need to be speaking with the same message. And not only in the office, but we also need to remember we’re all part of different organizations within our community, whether it may be faith-based, community-based or others, if we’re to achieve our goals of better protecting our patients with vaccination, we need to take the opportunity to spread those messages beyond just the healthcare setting. And that’s part of why I think efforts like this, on a national basis, hopefully we can all then, to take the cancer model, metastasize the message within our communities, within the other areas that we live beyond when we wear our neckties.

CHARLEY JOHN:  I’ll follow up to that. All those statistics are so true and it’s important to know that we have to start doing something about it and that that can make a difference. I had mentioned the partnership that we do with HHS on providing vouchers for their community immunization program. I participated in this, not only as a pharmacist, but also when I was supervising the region out here and having all of our pharmacists participate on it. It was amazing to me, it was stunning to me to go out into these communities and these are folks that are uninsured or under insured, but pretty much they basically didn’t have a place to go to get an immunization and they couldn’t afford it anyway, so this was really bridging those gaps. But to hear the information coming from their mouths as to, you know, what they think about immunizations and why they don’t think it’s important, or I don’t have a place to go, or I can’t afford it, it’s unbelievable how many of those folks are out there. But we started this program, and the stats were on there, but it’s amazing how many people, year after year, do start coming back. And if we can start influencing a few of those folks to start taking this seriously and the importance of it, they start telling their family members, they start telling their children, and we can start bridging those gaps around education and awareness.

SARAH DASH:  Thank you. Question from the back?

AUDIENCE MEMBER:  Thank you so much for this excellent panel. [inaudible—no microphone]. My question is: What can be done about it by people in the room, what can be done by people in this building? Is it the federal health department that needs to be looking at this and what can they do? Any thoughts … [inaudible]?

SARAH DASH:  Thanks. Good.

1. L.J. TAN: Oh, Sarah just looked at me. [Laughter] John, thanks for a great question. I think the question of what can be done, I think you kind of have to take a look and see where the gaps are in the system, where we can implement this, and I think one of our huge challenges is, you know, the idea that we’ve got an access problem for adults, and I think one of the challenges is that if you look at where people can get vaccinated, there’s firstly, providers are challenged to give vaccines because of the fact that they believe, rightfully or wrongfully, that they’re losing money on giving vaccines. So that’s one gap that I think we can address that’s outside, obviously, the Hill. But it’s something that we have to think about is why these gaps exist. So, for example, Dr. Hopkins brought up this idea of physicians trying to manage within the Medicare Part D system, you know, and the whole Medicare Part D system requires a physician to essentially say either you go somewhere else to get vaccinated, which is that missed opportunity that we’ve heard about, or if the physician wants to give the vaccine, the patient has to pay out of pocket. So there’s a policy, legislative change that could happen that could make it a lot easier for patients to get Medicare Part D vaccines, so that’s something that we can all think about going forward. It’s a real challenge, but something to think about.

Another big thing that’s out there that we hear, and this is as our systems are moving from what we call volume to value, and a lot more of our medical care, we’ve got transforming medical care, it’s moving towards healthcare systems, so healthcare is based in large systems now. And what we’re hearing when we go out there and we talk to these folks is that the challenges to vaccinating adults lie in the fact that there’s no data integration, so what happens is that you’ve got an adult patient that comes in, and the patient, you can’t access whether that patient’s been vaccinated for, let’s say, pneumococcal vaccination, and so then the provider or the system goes, well, if we vaccinate this patient and the patient has been vaccinated, the payer will likely not pay and we will lose money so, therefore, I will play it safe as a system or as a physician practice, I will not vaccinate until I know for sure that I am going to get reimbursed, right? Nobody wants to go out of business, right? And so, one of the best things we can do right now is figure out this data integration process, and I think we had a lot of work going forward in that at the federal level when we had, obviously, meaningful use, and that was when we had deadlines to get data integration between the state immunization information systems and the electronic medical records that all our patients are beginning to be enrolled in, because once we do that, then it becomes a lot easier, because once we do that we now have patient history, and when the patient history of vaccination is now inside the medical records – and for those of you who are not aware, once we can do that, we can do things like remind or recall. We can ping the patient saying, “Hey, by the way, you have diabetes, you need pneumococcal vaccination, please come in.” We can ping the provider for that patient saying, “Do you know that Mr. John has cardiac disease and needs influenza vaccine? He has not received it. Please make sure you get it to him on your next consult.” Those are all tools that we have but cannot use because the fundamental data integration component is missing, and I think that’s something that can be fixed at the federal and state level. That’s just two, John. I could keep on going, but I’m going to stop and say if anybody wants to talk to me about what we can do, please catch me at the end of this thing.

1. ROBERT HOPKINS: Thank you, L.J. You said that so much more eloquently than I would have. [Laughter] The other piece that I would say is it needs help from people in buildings like this is Medicaid rules on what they cover for vaccines vary state by state. There are minimum requirements, but there are also a great deal of differences on what’s going to be covered as far as adult vaccines in Medicaid programs across this country, particularly in relevance to adults. Again, we have a system for childhood vaccines that we don’t have for adults and I think many of us in this room have talked about a vaccine for adults program would be a great goal long term. It would help fill a lot of these gaps, but we’ve got a long way to go to get there, and it would require a lot of legislative will, as well as public and provider encouragement.

CHARLEY JOHN:  And, real quick, so we’ve all talked a lot about cost to the patients here and this, you know, it really isn’t about vaccines. I’ve dealt with medicines all my life and folks forego their medicine because they can’t afford it, so the same theory applies to vaccines. We have seen in patients getting vaccines at our pharmacies some very high co-pays. That’s the reason why I said that patients walk away, and they’re like, “It’s not worth to pay that much.” So there are some real policy efforts that can be made to reduce that. I don’t know if anybody works in CMS regulatory policy, but they just recently released Medicare Part D Call Letter. They have a provision there to encourage Part B sponsors to eliminate or reduce Part B cost-sharing for vaccines. So it’s a recommendation moving towards that direction, but it shows you that there can be some modification to benefit design that could make that happen.

And then, real quick, I’ll mention just to build on Dr. Tan’s point, the communication aspect, data sharing aspects, so, so important. We mentioned that the neighborhood concept, you know, we can’t approach vaccinations in silos. It can’t be a pharmacist doing their own thing or a clinical over there doing another thing, and a doctor’s office doing that. If all we had to do is immunize the 50 people in this room then, yeah, we could probably do that. I could take care of it myself, but we’re talking about 300 plus million people. You need a program where everybody’s talking to each other. The patient that I talked about, she didn’t remember if she had gotten her Tdap vaccine, so to pull on that story, I did actually give her the Tdap later on when I gave her her shingles shot; it was about four weeks later. In that meantime, I went about trying to find out if she got the Tdap vaccine. Really, my only resource was to be able to call her doctor and get – the registry systems were maybe not as robust at that point, but if we did have that data sharing, I wouldn’t want to miss that opportunity – somebody mentioned it earlier – to not know if she had it or not. I need to know right then and right now so that I can give her her immunizations and she can be on her way otherwise she’s not coming back.

SARAH DASH:  Thanks. And I actually wanted to follow up on that data question because, you know, you all talked about the importance of data integration, and what you’ve described is obviously an incredibly fragmented system for getting vaccines and so, and Dr. Hopkins, you mentioned kind of the need for documentation. I’m just wondering, can you just bring it down a little bit more to the sort of tangible day-to-day level, like do you have to report to a state system and then to the AMR and then to something else, or how does that exactly work; and then, how do patients, you know, that was going to be one of my other questions, how do you even know? I mean, especially for the vaccines that are not annual, how can people keep track and how can we help people with that?

1. ROBERT HOPKINS: I grew up in an era where everybody had a little yellow card. You don’t remember the yellow cards? And that was the way that you kept up with your vaccines, was the yellow card you or your mother or your father kept in their wallet, and the doctor’s office had a paper record that showed the vaccines given. Currently there is an immunization registry in every state in the Union, in many cities and many counties. Some of those registries talk to each other, but most of them don’t. If you have a certified electronic medical record in this country there is a meaningful use requirement that you have outbound interface from that EMR to the immunization registry in your locality. Generally it’s state. There’s not a requirement for bi-directional. Bi-directional, meaning going out as well as coming in was an earlier meaningful use requirement that was rolled back. So it helps having that outbound interface from our electronic medical records system. Where I work at the university, we actually have bi-directional interface. What we do for information from our pharmacies, the pharmacies in my area don’t report to the registry; they’re not required to. But if my patient is vaccinated at, and I’ll use Dr. John as my left hand, at a Walgreen’s pharmacy the pharmacists in our area are very good about asking who is your primary care physician? If he finds out that I am the primary care physician, I’m going to get a message coming in through our pharmacy interface to say that they were vaccinated with what vaccine, when, what the lot number was, and then I can, at the back end, enter that into our EMR, which goes to the registry, but that’s a manual process. If they were vaccinated at some other facilities, either from a mass immunizer or some small mom and pop pharmacies or other areas, they may not get anything that’s put anywhere that I can see as the primary care physician. So there are a tremendous number of holes in the process. How much adult data is in the vaccine registries across this country varies tremendously. Some states have a lot of adult data, some states have almost none. It’s required for childhood, but it’s not required for adults.

CHARLEY JOHN:  I’ll just add. Today this is our new yellow card and we’re really working to, you know, provide patients their information so that they can take charge and be activated about their health so within our app we’re trying to add a lot of capabilities for patients to do that. But there is this just basic concept, and I know it’s a lot easier said than done, but you have to have connectivity. Each physician office uses their own EHR and they may be on a different system and some connect and some don’t. Pharmacies are not required to report to immunization registries. We pretty much all do. We may not be able to report to all states and that’s because there are some of these technological barriers that exist that don’t need to really exist. We could probably minimize those and simplify those things and make that happen, make this seamless. So we need to have connectivity in our mind. Whatever we can do to make that happen, let’s get the policies below that in place to achieve that.

1. ROBERT HOPKINS: I still tell people, routinely, that are in my office, you know, we’re giving you this vaccine today. I want you to take your cell phone out and take a picture of the immunization screen. Keep that. I want you to keep your problem list and keep your medication list on your phone, that way you’ve got it if, heaven forbid, you’re in Washington, D.C. and you’re in a car accident, and you need this information. At least it’s there on your person and more likely if you had the data than for somebody to try to go figure it out somewhere else.

1. L.J. TAN: I think this is one of the things that we’ve got to figure out also. It’s not just at the federal level, but also at state levels, that we need to figure out how to incentivize all providers reporting to the immunization registry and also make it easier for that to happen. Some of the meaningful use things that Dr. Hopkins talks about would have been, you know, especially the bi-directional flow requirements, which now has gone away, would have been really useful for that. So that’s something to think about going forward.

The other thing I also kind of remind people about the registry is that there’s validation in that process which needs to happen. And so, while these apps – and nothing against the Walgreen’s app, because I use it, it’s great for personal information. It’s not validated with the registry and that data has to be validated in order for that vaccine to be recognized as good. So that’s a challenge. The validation process is something that still has to think about. You know, I’ve always – because the registry can exist at the state level, and I can understand that there’s ownership of that data, I’ve always been one to think about how can we get all our states to think about a Cloud. How do we do Cloud computing with our registries? And I know there’s a lot of resistance to that, but that’s something that I put out here for controversial thought and process, so I think it’s something that’s interesting that we can think about. And then, you know, it’s interesting, because I’m always – I was told this by a friend of mine who works in finance and we have these great conversations about IT – health IT in the United States, it’s really interesting because health in the United States is, I understand, is now like an $80 billion per year industry, and what’s remarkable is that if we apply the health IT framework in technology that we have to finance, your ATM withdrawal would take three days. [Laughter]

AUDIENCE MEMBER:  [inaudible—no microphone].

1. ROBERT HOPKINS: Well, there are a number of different things out there that play into vaccine hesitancy and vaccine objection, and probably one of the best diagrammatic ways I’ve seen it referred to was done by an author by the name of Tara Haelle – H-A-E-L-L-E, shows that it’s really a spectrum. You’ve got those that are at one end of the spectrum that are the hard core anti-vaccine evangelicals; at the other end of the spectrum you probably have folks that just don’t have a whole lot of knowledge; and, in between, you’ve got people with various levels of objection, to disinterest, to trust issues, and that type of thing. And I think it’s important for clinicians and for those of us that are advocating for this issue to do two things. Number one is you have to be a diagnostician when you’re speaking with somebody about vaccines. I need to be able to look, listen, and feel, so to speak, the patient that I’m talking to and figure out where they’re coming from first. If you’re a hard core anti-vaccine person that’s evangelical that vaccines are bad or dangerous or evil, I can speak until the cows come home, pardon my Southern expression, about any aspect and I’m not going to get anywhere. In my view, that’s somebody that you probably need to say, “I’m sorry you believe that. The facts are not in accord with what you’re saying,” and step away with respect, with that said. If it’s somebody that doesn’t have good knowledge about vaccines and the benefits, we can talk about knowledge and benefits. If it’s someone that’s motivated by their family or their community, you know, a grandmother that says, “No, I don’t want that flu shot, or that other vaccine,” but she tells you that she’s getting ready to go visit her grandchild, we talk about the benefits of that vaccine to the grandchild and to the rest of the family. Oftentimes, that’s going to be a motivator more than it is talking about the benefits to her. So if you diagnose what the challenge is first you’re much more likely to have an effect on that individual and I think that’s something that is easier to do when you get a bit of this gray stuff in the hair. Many of my younger residents and students have a harder time with that concept. They say, “Well, we just tell them it’s good.” [Laughter] That doesn’t get us there.

1. L.J. TAN: You know, I have to jump on that, Bob – Dr. Hopkins, because I think this is the challenge and I think, you know, what we’re realizing is that we train our physicians incredibly well and we train them with a lot of information and they have so much training, but we don’t train them on risk communication and risk management. And what it has become for vaccine confidence, it’s not an issue of science, as you have pointed out, it’s an issue of risk management, risk communication, and so this is where, I think, Bob’s pointing out is that I think, you know, as you get older and you get grayer, and I’m grayer than you are, Bob, you figure out how to listen to your patient, right, which is what you’re trying to figure out. Listen to the patient and then react to that patient. And the patient body, as Bob’s pointed out, is this idea, this middle ground. You know, this is the middle ground that you’re trying to wrestle for, and the message is not one size fits all, which is why it’s so challenge, and that’s the cardinal thing about risk management. You can’t do a one size fits all type component. I do vaccine confidence training, and one of the things, you know, with the young physicians, one example I’m going to give to you, it’s a great story, is, you know, I give a scenario training where I say, okay, so let’s say you now have a patient in front of you, it’s a young man, and he says, you know, “I’m not going to get the flu vaccine and the reason I’m not going to get the flu vaccine is because, you know what? I got my grandmother to get her flu vaccine and guess what? She got the flu from the vaccine.” So what’s the first thing that you say to this patient, this young gentleman who is concerned about his grandmother sitting in front of you? The doctors, 98 percent, will say, “Well, your grandmother couldn’t have gotten flu from the flu vaccine because it contains inactivated virus, so she definitely didn’t get flu from the flu vaccine.” And I would look at them and I would say, “Alright, did you just share what this young man had told you? Why didn’t you just start with, ‘so how is your grandmother,’” right? So those are the things that we’re now trying to build into that communication process, and I think Bob would probably, Dr. Hopkins would probably say, I think there’s so much that we’re asking all our providers to do, right, including our pharmacists that it’s just one other thing that we now have to figure out a way to put that in there.

And while I have the floor, I’m going to talk about a policy thing, too. I think this idea of quality measurement has not been brought up today, and I think it’s something that we should think about because, you know, Laura mentioned it at the beginning, that I think we measure what we treasure is how I like to say it, as opposed to, you know, what gets measured gets done. So I think we need to treasure adult immunizations enough that we measure how we perform in it. And I think there’s a lot new measurements that are coming out that we could do with a lot of Hill and federal support. In CMS, there’s a maternal immunization measurement that’s now coming out. There’s an adult composite measurement that’s now coming out for adult vaccines. So those are things that are coming through the process of public comment, so I think it would be really cool if we could see some of those measurements get implemented across the country.

Sorry to turn the topic for you, but I figure I had the floor.

SARAH DASH:  Well, I’m glad you brought that up, actually, because on that theme of quality measurement, outcomes, and you mentioned earlier, kind of value over volume, and accountability, and Accountable Care, and we’ve talked a little bit about Medicare Part B payment for physicians. We talked about Part D, the prescription drug program, of course, and we haven’t talked a lot about Medicare Advantage and, of course, Medicare Advantage doesn’t always cover Part D drugs. Sometimes you have to have a combined plan or sometimes they’re separate, but I’m wondering if anyone can talk about the role of Medicare Advantage in the Medicare program because it is, at least, 30 percent, right now, of enrollments and growing.

1. ROBERT HOPKINS: Medicare Advantage is a wild card, and for flu and pneumococcal it’s easy, for hepatitis B it’s easy, but the challenge is when it comes to Tdap, when it comes to shingles vaccine, there is no way for me, as a provider, to know whether it’s going to cover those vaccines or not. Most of the patients that I see that have Medicare Advantage plans; they have a portal that they can go to to ask specific questions. We try to make it available for them to have a computer to do those, if they have questions about vaccine access, in the office, but there’s not an easily transparent way of asking that without going to their particular plan. We try to keep up with the one or two most common ones that we see patients in our practice, but I think, in my practice, the last time I looked a few months ago we had fourteen different Medicare Advantage plans that were supplying coverage to a large number of patients in our practice and there’s just not a good effective way to keep up with all of those.

1. L.J. TAN: I’m going to just pop in here and talk about the policy of Medicare Advantage plans because I think there’s some policy things that can happen. So I think, so Dr. Hopkins is absolutely right, but I think there are some examples of some really good practices that going out there. In Utah, there’s a healthcare system, and this is why I always go back to systems, right? Volume is going down, value is going up. And Intermountain Care in Utah basically recognized the fact that there is value to be had in vaccinating their adults, including those that were covered under Medicare Part D as in dog, the D plan – the shingles, the Tdap, for example. And what Intermountain did was, they worked with all their Medicare Advantage plans to essentially say that, you know, through our arrangement, you will cover, without question, all the Medicare Part D vaccines. So that was a policy change that happened in the system. So if you’re in the Intermountain Healthcare system you would get vaccinated and it would be covered, and you wouldn’t have to question it, and the provider wouldn’t have to question it, and so the vaccinations happen and their rates went up. I think those are the things that, you know, policy wise, we can think about that. That happened at the state level with one healthcare system, but I think we need to start working with healthcare systems thinking that way.

1. ROBERT HOPKINS: And, again, it’s economies of scale, or what allow you to have those negotiations at those levels and make policy changes. I think that’s one opportunity that may be out there for this growth of Accountable Care Organizations, is they’re going to get a bigger opportunity to potentially negotiate across larger populations of patients with Medicare Advantage plans or others.

CHARLEY JOHN:  And, I’ll say, we don’t deal a ton with Medicare Advantage. Certainly, the Part B side, if it’s a combined plan, but I think, you know, when we talk about quality measurements and things like that, there is a basic disconnect on why sometimes we can’t incent quality measures, but I think Medicare Advantage can kind of bridge this gap, and I think as we see maybe Medicare Advantage perhaps moving into the quality payment program space we’re going to see some more formalization of this. But we mentioned the vaccines that are covered under Part D, and then the chart shows you how many billions of dollars are saved from vaccine-preventable disease in those regards, well, the Part D plan never really sees that, right? Those savings are going to be realized in Part A and Part B. So that kind of disconnects, loses, you know, the Part D plan is going to lose a little bit of incentive. I’m not suggesting what that exact fix is, but framing that basic concept and how we should approach that.

SARAH DASH:  And as a former Hill staffer and knowing that, you know, as people are looking at savings and what that really means, that can be a real challenge if, you know, the money that could be saved by more effective uptake of vaccines doesn’t really get scored at the federal level because of those disconnects.

Anyone else want to comment? Great. Well, we have a couple of minutes left and I just want to pause and make sure that everyone was able to get their questions answered.

AUDIENCE MEMBER:  [inaudible—no microphone].

1. ROBERT HOPKINS: Great question. You know, we have a number of things that are in the strategic national stockpile for pandemic preparedness. Some of the influenzas, for example, but if we have an emergency, similar to what we have right now with a “standard influenza” that is hitting our country really hard, there’s not a strategic national stockpile of a vaccine. We do have stockpiles of Tamiflu, which is a flu antiviral that can be effective, and I think some of that has been released to the public in areas where there have been spot shortages of an antiviral medication, but this, again, speaks to the challenge I think that Charley spoke of briefly in his comments that if we get into a pandemic situation, whether it’s from influenza, measles, anthrax, whatever else, we are really in an interesting situation. We’re probably better prepared now than we were 20 years ago, but we’re not as well prepared as we need to be in the situation where we have a widespread pandemic of a vaccine-preventable illness. If it happens to match with what’s been developed as in the national stockpile we’ve got a starting point, but there are a lot of potential – we take the example of measles. Look at the outbreak we had in Minnesota a year ago. We had an outbreak of a vaccine-preventable disease that we have an extremely effective vaccine for because people didn’t believe in the vaccine or thought it was harmful. Those types of things were probably at greater risk for, in my mind, than we are for something that we may be well prepared for.

1. L.J. TAN: And I’d like to take that to federal, as well. Back to that whole concept of 317 Program Coalition funding, the 317 Program Funding, as well, and the reason for that is I think that one of the best things we can do to be prepared for emergencies and pandemics, for example, is to have an infrastructure that supports what we need to do every year, and that takes me to this idea of, you know, I like to say our failure to vaccinate our public, our elderly and our adults with flu every year predicts our failure to vaccinate them in the time of pandemic. It’s absolute. And I think, you know, if we can deliver flu vaccine to all our elderly and to all our adults every year consistently because we have the capacity and infrastructure to do so I think we would so much more prepared to do so for pandemics, as well. And that same infrastructure that we developed isn’t just for flu vaccination. You can use it to deliver pharmaceuticals, antibiotics – it’s the same public health infrastructure that we keep going back to, as we all know, is extremely fragile in this country. I think there have been many reports from Trust for America’s Health, from National Foundation of Infectious Diseases that highlights this. So I think that’s where we could do federally, is to try to improve funding and support for that infrastructure which is so critical.

SARAH DASH:  Thank you. I think Charley has something to say, and I think Dr. Chen has something to add.

1. WILBUR CHEN: Yeah, I finally feel like I can answer somebody. [Laughter] A lot of questions were policy related and other things that are not within my expertise, and I’m a scientist and I work on burden of disease and evidence for efficacy, and a lot of what we do at the Center for Vaccine Development is pandemic preparedness, so that’s a great question. I don’t work in the policy realm of implementation, but a lot of the science behind pandemics is what you’re talking about is that there’s this huge shifting perception and fear, and that’s what drives a lot of behavior, and a lot of vaccine hesitancy is a lot on behavior, so there’s a lot of science behind that, as well. So that perception and fear completely shifts and so all of a sudden you’ve got a population that perceives that there’s something there that is harmful and all of a sudden they perceive that there is something valuable, like a vaccine or a therapeutic, that they all want to get, and that’s a shift from what you see from year to year, and so it’s a different type of psychology, which means that you have resources, again, like L.J. was saying, is that we’ve got resources that exist and there’s a real value every year for vaccination, and we should be building upon that, but unfortunately there’s a public perception that there is not much value and that these are just some of the hesitancies, some of the poor uptake. Maybe there are policies that need to facilitate uptake and those sorts of things, but again, pandemics are different. And they only come occasionally, but then we also have situations like Ebola and Zika, those sorts of things that, again, stir up interest but temporarily. And funding comes and it goes away. And so, you can’t build ongoing infrastructure with resources that come very suddenly and then disappear suddenly. You can’t build anything sustainable. So I think that we have to think about sustainability, and that goes back to, again, we have to have an attitude that the resource that we have there we should be using. We should be trying to increase uptake of vaccination from year to year. That’s why we have those Healthy People 2020 goals that we’re not reaching, and we should all identify that that is an important goal for all of us to be reaching toward and not wait for a pandemic. But you’re right. These pandemics are very important, as well, for us to be thinking about. But we should be using our ongoing infrastructure and improving policies around what we have right now, because there is also not a pandemic but there is a burden of disease that is present every year.

SARAH DASH:  A final two comments.

CHARLEY JOHN:  I’ll be quick. It’s a great question and my point of view is more just about process, that we just want to say that pharmacists could and should be involved if we really want to make an effort here. If I think about this current season, the flu outbreak, I think about the state of New York, they, about three weeks ago, put out their statewide emergency for allowing pharmacies to provide immunizations. I would say that it was a little bit too late, and it doesn’t allow pharmacies to really enact there. You know, we have over 40,000 community pharmacies across the country. We want those to be access points if we need to have this rapid and widespread and a cog in the infrastructure that can communicate with other facilities as well, so we don’t want pharmacist’s store to be limited so that they can’t be involved in the response. If this was two years ago and we were dealing with Zika and if tomorrow a Zika vaccine was developed and approved, pharmacists would not be able to help on it. So we don’t have the time to kind of wait and catch up for it to happen. I know a lot of this stuff occurs at the state level and that policy is involved, federally speaking, I know the pandemic and All Hazards Preparedness is being looked at, so there could be some opportunity there, but I think pharmacists playing a bigger role in here is going to allow to have a more complete response.

1. ROBERT HOPKINS: And Wilbur said a lot of the things I was going to point to, but again, it all comes down to we all need to be engaged and involved as individuals, as members of organizations. We need to talk t our legislators. We need to talk to those in our community about the value and benefits of vaccine, whether on a pandemic side or a routine disease like influenza that we’re not doing a very good job protecting our public from.

SARAH DASH:  Well, thank you all. You’ve taken us on a real journey from, as the phrase goes, I guess, bench to bedside, or from the science to the actual shot in the arm that people need and then beyond to the impact on health and community and lives, so we’ve learned about the high-tech things that need to happen from error connectivity to the low-tech just pure listening to the payment reforms that might be needed and then the practical implications of those. Thank you all. I want to thank everyone in the audience for coming and, once again, to thank the Adult Vaccine Access Coalition and JSK for their support. You’re going to join me in thanking our panel, but please, before you leave, there’s a little blue evaluation form in your packet. We’re all about data and quality metrics at the Alliance for Health Policy, so please fill out your blue evaluation form and suggest future topics for briefings that you’d like to learn about. So thank you to our panelists, and thank you to all of you.

[Applause]