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Vaccine
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Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia
Kenji Adachi a,∗ , Margaret S. Coleman b , Christopher de la Motte Hurst b , Monica L. Vargas c , Alawode Oladele d , Michelle S. Weinberg b
a
Bayer Yakuhin, Ltd., 4-9, Umeda 2-chome, Kita-ku, Osaka 530-0001, Japan Centers for Disease Control and Prevention, Division of Global Migration and Quarantine, MS E-03 1600 Clifton Road, Atlanta, GA 30333, United States Georgia Department of Public Health, Division of Health Protection, 40 Pryor Street, Atlanta, GA 30303, United States d DeKalb County Board of Health, Refugee Health Program, 445 Winn Way, Decatur, GA 30030, United States
b c
a r t i c l e
i n f o
a b s t r a c t
Background: Approximately 70,000 refugees are resettled to the United States each year. Providing vaccination to arriving refugees is important to both reduce the health-related barriers to successful resettlement, and protect the health of communities where refugees resettle. It is crucial to understand the process and resources expended at the state/local and federal government levels to provide vaccinations to refugees resettling to the United States. Objectives: We estimated costs associated with delivering vaccines to refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). Methods: Vaccination costs were estimated from two perspectives: the federal government and the DeKalb clinic. Data were collected at the DeKalb clinic regarding resources used for vaccination: staff numbers and roles; type and number of vaccine doses administered; and number of patients. Clinic costs included labor and facility-related overhead. The federal government incurred costs for vaccine purchases and reimbursements for vaccine administration. Results: The DeKalb clinic average cost to administer the first dose of vaccine was $12.70, which is lower than Georgia Medicaid reimbursement ($14.81), but higher than the State of Georgia Refugee Health Program reimbursement ($8.00). Federal government incurred per-dose costs for vaccine products and administrative reimbursement were $42.45 (adults) and $46.74 (children). Conclusions: The total costs to the DeKalb clinic for administering vaccines to refugees are covered, but with little surplus. Because the DeKalb clinic ‘breaks even,’ it is likely they will continue to vaccinate refugees as recommended by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices. © 2012 Elsevier Ltd. All rights reserved.
Article history: Received 27 April 2012 Received in revised form 25 July 2012 Accepted 8 August 2012 Available online xxx Keywords: Cost analysis Refugees Vaccine reimbursement
1. Introduction Approximately 70,000 refugees are resettled to the United States annually [1]. Before departing overseas locations, refugees receive a pre-departure medical screening that includes few, if any, vaccines. Refugees in camps (as opposed to urban areas), primarily young children, receive some vaccines through the World Health Organization’s Expanded Programme on Immunization. However, this vaccine package does not include all vaccines recommended
∗ Corresponding author. Tel.: +1 404 639 7023; fax: +1 404 639 4441. E-mail addresses: [email protected] (K. Adachi), [email protected] (M.S. Coleman), [email protected] (C. de la Motte Hurst), [email protected] (M.L. Vargas), [email protected] (A. Oladele), [email protected] (M.S. Weinberg). 0264-410X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2012.08.016
for children in the United States, and provides very few adult vaccines. Further, implementation varies depending on camp location and refugee age. While rare, several vaccine-preventable disease outbreaks have occurred in U.S.-bound refugees. These outbreaks have a negative impact, delaying refugee resettlement [2]. In addition, the importation of even one case of any vaccine-preventable disease creates a domestic exposure risk to unvaccinated people. These events require costly public health responses to isolate and mitigate the risk of further domestic transmission [3]. After arrival in the United States, refugees are vaccinated during initial medical screenings, usually conducted 1–3 months after resettlement. Financing of vaccine purchases, vaccine administration, and medical screening is complex and is comprised of several mechanisms, Vaccines for Children (VFC), Medicaid, and the federally funded but state-administered Refugee Medical Assistance
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
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program. We conducted an observational investigation that estimated costs of vaccinating refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). DeKalb clinic costs were then compared with likely payments from all sources to determine whether clinic expenditures were covered by reimbursements. Our study is unique in several regards. To the best of our knowledge, there are no published studies examining the vaccination process for both children and adults. Previous studies focus on either pediatric or adult vaccinations [4–6]. The DeKalb clinic also delivers larger numbers of adult vaccines than reported by other medical practices [7]. Finally, perhaps the most important unique characteristic is that there are no other studies of the economics of clinic-level vaccination that include observed numbers of both patients flowing through a clinic and vaccine doses administered. Currently published studies of large-scale influenza vaccination pilot projects or initiatives have observed numbers of doses and patients, but these are one-time events, not established medical practices [8–10]. Publications that estimate costs and effort of vaccination in established medical practices either model or assume total patient flow and numbers of doses of vaccine administered [4–6,11–13]. Our unparalleled access to DeKalb clinic records provided directly observed data of total numbers of patients and vaccine doses, and allowed for more accurate estimates of labor time and associated costs. This study was initiated in the Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC) because of an interest in comparing overseas vs. domestic vaccination programs. In a subsequent manuscript we will report the overseas portion of the ongoing study to analyze refugee vaccination options. 2. Methods Approximately 2000–4000 refugees arrive in Georgia annually; 90% receive their initial medical screening and vaccines at the DeKalb clinic. This investigation was determined to be nonresearch by CDC. 2.1. Study perspectives Most domestic costs of vaccinating refugees are incurred by two stakeholders: the federal government for vaccine purchases and administrative reimbursements; and the local medical clinics that vaccinate refugees during their initial domestic medical screening. Vaccination costs were estimated from the perspectives of the federal government and the DeKalb clinic. 2.1.1. United States federal government and reimbursement structure From the federal government perspective, costs of vaccinating refugees include funding to purchase vaccine products (e.g., measles–mumps–rubella (MMR)) and funding to reimburse for vaccination administration. Federal funds are distributed to the state of Georgia through a complex of funding vehicles. Vaccine products are provided free of charge to the DeKalb clinic, but are paid through: VFC; Section 317 grants program; Medicaid; or the Cash and Medical Assistance (CMA) program. Georgia uses a mix of funding to purchase vaccines and distribute them to the DeKalb clinic while vaccination administration reimbursements are paid through the Georgia Medicaid program and the State of Georgia Refugee Health Program (SRHP). Georgia Medicaid (for children, PeachCare) and SRHP pay different levels of vaccine administration reimbursements and pay for different numbers of vaccines and different vaccine-eligible populations. SRHP reimburses only for adults (21 years+) and for the first dose of 6 vaccines. SRHP
does not reimburse for the second or third doses in vaccine series requiring multiple doses over time. Series are hepatitis A (2 doses), hepatitis B (3 doses), MMR (1 or 2 doses), tetanus–diphtheria (a booster every 10 years)/tetanus–diphtheria–acellular pertussis (1 dose), pneumococcal (1 or 2 doses), and varicella (2 doses) [14]. Georgia Medicaid reimburses for administration of every dose of all pediatric vaccines and for second and third doses of adult vaccine series. SRHP reimburses adult vaccination administration at $8 per dose/injection to a maximum of $48 per refugee. Medicaid reimburses a $14.81 payment per dose/injection for subsequent doses of adult vaccines and for all pediatric vaccine doses with no upper limit. SRHP is funded by the federal government through the CMA. The funding for Georgia Medicaid is shared between the federal and state governments at contributions of 65.33% and 34.67%, respectively [15]. VFC, Section 317, CMA, and SRHP programs are briefly described in supplemental materials (Appendix A). 2.1.2. Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic) The DeKalb clinic does not pay for vaccine products, but does incur labor and facility-related overhead costs associated with the vaccination process. The process includes ordering, storing, maintaining the cold-chain, vaccinating and educating patients about vaccine medical benefits and risks. As part of the DeKalb clinic perspective, we compared the data on Medicaid and SRHP reimbursement with the labor and overheard cost estimates to determine whether reimbursements cover the costs of the vaccination process [4–6]. The DeKalb clinic follows the Advisory Committee on Immunization Practices (ACIP) childhood and adult vaccination recommendations except for hepatitis B virus vaccination. In addition to routine ACIP recommendations, the Georgia Department of Community Health, Division of Public Health, recommends hepatitis B virus vaccine for all refugee adults who do not test positive for hepatitis B virus infection [16]. 2.2. Primary data Primary data regarding clinic operations and resource use were collected during visits to the DeKalb clinic. During one visit two investigators observed program activities, obtained employee information, such as the number of clinic staff and their titles and roles, and collected data about the numbers of vaccinations administered and patient visits from clinic superbills (dated February 28–March 4, 2011). Superbills are a form used in medical facilities to record services provided to patients during a visit. At the DeKalb clinic, patients who are vaccinated receive two superbills, one for the clinic visit and one for vaccine administration. The vaccine administration superbill records the type and number of doses of vaccines administered. In addition to the data from observation and superbills collected during our initial visit, we also collected data from two additional weeks’ worth of superbills (April 4–8 and 11–15, 2011) to document the types and numbers of vaccines over a longer period of time. We made a second visit to the DeKalb clinic to verify details of our data collection with the staff (Appendix B). 2.3. Vaccine product costs The vaccine product costs were estimated using VFC prices. The federal government negotiates vaccine product prices with manufacturers for the VFC program [17]. The federal government then provides VFC funding that can only be designated for vaccine purchases and Section 317 block grant funding to cover additional vaccines (e.g., adult vaccines) or program costs to states. States determine what types of, and how many doses of, vaccines to purchase at the listed VFC prices, and use VFC and 317 funds to make
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
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these purchases. About half of all states add state and local funding to federal funding to round out vaccine purchases. States then distribute vaccines to VFC-participating medical practices; the DeKalb clinic receives vaccines free of charge from Georgia [17,18]. Refugee demographics and circumstances, e.g., age and whether or not they have immunization records, determine the vaccines received by each refugee. To obtain representative estimates for groups of refugees, we calculated the average costs of vaccine products provided during the three-week study period in two steps. First, the total cost of vaccines was estimated by multiplying the number of doses of each vaccine (pediatric or adult) by its VFC price dated April 11, 2011 [19]. Second, the total costs of vaccines were divided by the total number of vaccine doses provided over the study period. 2.4. Employee compensation To determine the cost of DeKalb clinic labor, we used wage data from the Bureau of Labor Statistics’ Occupational Employment Statistics (OES) [20] and DeKalb clinic records of numbers of employees and titles/roles (Appendix C, Table C1). Thirty-eight percent was added to wages to calculate total employee compensation [21]. Compensation was further adjusted for inflation using the consumer price index for medical care services [22]. 2.5. Modeling labor costs All medical practices, including the DeKalb clinic, employ two types of labor. In general terms, medical-needs labor time varies with the numbers of protocols or services and complexity of medical care, while operational labor time varies with the total number of patients and is approximately equal per patient [4–6]. 2.5.1. Medical-needs labor Staff providing direct medical services was categorized as medical-needs labor and their labor time-per-patient varies with the complexity and numbers of medical services, e.g., a patient getting several vaccines takes more nursing time than a patient getting one vaccine. In other publications, this type of labor is usually labeled “clinical labor” [4–6]. However, at the DeKalb clinic, interpreters are critical to medical care, but would not normally be thought of as clinicians, so we used the term medical-needs labor in this particular medical clinic setting. Medical-needs labor time associated with vaccination included the tasks of vaccine preparation, injection, record keeping, education, clean up, and language interpretation. The time for these tasks, except for interpretation, was calculated using an average of several published clinical times [11,12,23,24]. Average clinical time for first and subsequent doses was adjusted upward 27% to account for interpreter labor time [25]. The calculated medical-needs labor time was multiplied by weighted average staff compensation to estimate medical-needs labor cost for the first dose (Appendix C, Table C1). 2.5.2. Operational labor Operational labor refers to staff providing services per-refugee, such as patient check-in, superbill data entry, arrangement of appointments with refugee supporting organizations, or immunization registry. The study does not include labor time for follow up and missed appointments because data was not available. Operational labor time is an average-per-patient; for example, pulling medical charts takes approximately the same average amount of time per patient regardless of the complexity of care the patient receives. Operational labor time in the vaccination process was calculated by multiplying the total operational labor time per refugee by the percentage of time attributed to vaccination. This percentage was
estimated as the proportion of the number of vaccinated refugees relative to the total number of refugees cycling through the DeKalb clinic. The operational labor time associated with the vaccination process per refugee was multiplied by a weighted average staff compensation to estimate costs for this labor category (Appendix C, Table C1). 2.6. Overhead costs Overhead costs are defined as all facility-associated expenses other than labor compensation, such as utilities, malpractice insurance, nonmedical and medical supplies, and equipment (e.g., refrigerator to store vaccines). Overhead was estimated as 30% of the total labor costs [26–29]. 2.7. Sensitivity analysis Three one-way sensitivity analyses were conducted to examine the effects of the different assumptions on the estimated cost from the DeKalb clinic perspective: • Changed the model calculation for operational labor from the percentage of the number of vaccinated refugees relative to the total number of refugees to the percentage of time that medicalneeds labor devoted to vaccinating refugees relative to the total medical-needs labor time. (This alternative method to apportion operational labor time for the vaccination process was the primary method used in the overseas portion of the study mentioned in Section 1.) • Changed the percentage of wages used to calculate non-wage benefits from 38% to 26 and 50% [21]. • Changed the percentage of overhead relative to total labor costs from 30% to 50 and 100%. 3. Results 3.1. Labor time estimates The medical-needs labor time for vaccination was estimated at 9.3 min for the first dose and 3.0 min per each additional dose. By comparison, previous studies estimated 11 min for scheduled visits of adult influenza vaccination [4] and 6–7 min for other various vaccination settings in pediatric clinics (e.g., vaccination during well-child visits) [11,23]. The operational labor time per patient associated with the vaccination process was calculated from 7.3 to 11.3 min (9.1 min on average) for the three-week study period. 3.2. Number of vaccine doses and patients (Table 1) Over the three-week period of time for which primary data was collected, the total number of vaccine doses administered ranged from 422 to 668, and the total number of patients ranged from 549 to 811. Not every patient was vaccinated, but for those who did receive vaccines, the number of doses provided was approximately proportional to the number of vaccinated patients. Each vaccinated patient received an average of 2.01–2.33 vaccine doses during the three weeks of primary data. 3.3. Costs for vaccines The majority of adult vaccinations were for hepatitis B, varicella, MMR, and tetanus–diphtheria/tetanus–diphtheria–acellular pertussis (Table 2). The weighted average per-dose cost of adult vaccine products was estimated at $32.77.
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
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K. Adachi et al. / Vaccine xxx (2012) xxx–xxx Week 1a Week 2a Week 3a Average of the three weeks 251 260 512 236 2.16 671 35.3% 11.5%
Table 1 The number of doses of vaccines provided and the number of patients at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). Description The number of vaccine doses provided Childrenb Adultsb Total (children + adults) The number of patients/superbills for vaccine administrationc Average number of doses of vaccines per vaccinated patient/superbillc,e The total number of patients/superbills issued at the DeKalb clinicc The percentage of the number of vaccinated patients relative to the total number of patients The percentage of medical-needs labor time for refugee vaccination relative to the total medical-needs labor timef
a b
325 343 668 286d 2.33 811 35.3% 14.5%
230 215 445 221 2.01 654 33.8% 10.4%
199 223 422 202 2.09 549 36.8% 9.7%
Week 1: February 28–March 4, 2011; Week 2: April 4–8, 2011; Week 3: April 11–15, 2011. Children: 0–18 years old; adults: 19 years old and over. c A superbill is a form used by most healthcare providers to record the services provided to each patient. It is also used to bill for reimbursement from public and private insurers. At the DeKalb clinic, patients who are vaccinated receive two superbills, one for the clinic visit and one for vaccine administration. Because superbills are issued for every visit to every patient, we considered the number of superbills a proxy for the number of patients. d The information was not collected for Week 1. To derive this number, we multiplied the total number of patients in Week 1 by the average percentage of the number of vaccine administration superbills relative to the total number of patients for the other two weeks of the study period (Appendix B). e The average number of doses of vaccines per superbill was calculated by dividing total number of vaccine doses (the sum of vaccine doses for refugee children and adults) by the number of superbills for vaccine administration. f The percentages were estimated in two steps. First, overall medical-needs labor time devoted to refugee vaccination in each week was calculated based on the estimated clinical time of vaccination (i.e., 9.3 min for the first dose and 3.1 min for each additional dose) and the number of vaccine doses provided. Second, the overall medical-needs labor time devoted to refugee vaccination was divided by the total medical-needs labor time in each week (i.e., the number of full-time equivalent employees multiplied by 2400 work-minutes a week).
The top three pediatric vaccines, in terms of the number of doses provided, were inactivated poliovirus, hepatitis A, and varicella (Table 3). The weighted average per-dose cost of pediatric vaccine products was estimated at $37.06. 3.4. Costs for refugee vaccination 3.4.1. Federal government (Table 4) Given that Georgia receives 65.33% of its Medicaid funding through federal medical assistance [15], the federal share of vaccine administration reimbursement was set at $9.68 per dose (or 65.33% of $14.81 per dose). The initial and subsequent per-dose vaccine costs for adults were estimated at $40.77 and $42.45, respectively. The per-dose cost for pediatric vaccines was $46.74. 3.4.2. Board of Health Refugee Services, DeKalb county, Georgia (Table 5) From the perspective of the DeKalb clinic, the average labor and overhead cost for the first dose of vaccine was $12.70, with a range of $11.77–13.84. On average, medical-needs labor, operational labor, and facility-related overhead costs accounted for $6.13 (48%), $3.68 (29%), and $2.89 (23%), respectively. The results indicate that the Medicaid reimbursement of $14.81 covers the costs
for the first dose of vaccine provided to refugees during the three weeks, but the SRHP reimbursement of $8 does not. 3.5. Sensitivity analysis (Table 6) From the perspective of the DeKalb clinic, the primary analysis yielded a vaccination cost for the first vaccine dose of $12.70. • Changing the method of calculating the operational labor time from (a) to (b) below resulted in decreasing the average vaccination cost from $12.70 to $9.48. (a) The percentage of the number of vaccinated refugees relative to the total number of refugees cycling through the DeKalb clinic varied from 33.8% to 36.8% (35.3% as average) (Table 1). (b) The percentages of vaccination time relative to the total medical-needs labor time in each week varied from 9.7% to 14.5% (11.5% as average) (Table 1). • Changing the percentage of wages added for non-wage benefits from 38% to 26 and 50% resulted in average vaccination costs of $11.60 and $13.81, respectively. • Changing the percentage of overhead costs relative to labor costs from 30% to 50 and 100% resulted in increasing the average vaccination costs from $12.70 to $14.71 and $19.62, respectively.
Table 2 The number of doses, types, and price-per-dose of vaccines provided to adult refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic).a Vaccine Doses per week Week 1b Hepatitis B Human papillomavirus Measles–mumps–rubella Pneumococcal Tetanus–diphtheria Tetanus–diphtheria–acellular pertussis Varicella Total
a b c d
Public-sector per-dose price (US$)c , d Week 2b 69 0 39 0 40 22 45 215 Week 3b 59 0 41 2 47 27 47 223 28.00 89.17 33.61 20.57 13.82 26.25 55.36
Total costs of each vaccine for the three weeks (US$)d
90 1 54 5 53 45 95 343
6104.00 89.17 4504.28 143.98 1934.80 2467.50 10,353.07 25,596.80
Adult: 19 years old and over. Week 1: February 28–March 4, 2011; Week 2: April 4–8, 2011; Week 3: April 11–15, 2011. Data are extracted from the CDC vaccine price list dated April 11, 2011 (one that is close to the end of the study period) [19]. Prices and costs are in 2011 dollars.
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
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K. Adachi et al. / Vaccine xxx (2012) xxx–xxx 5 Doses per week Week 1b Week 2b 8 35 28 5 22 18 10 11 43 7 11 23 6 3 230 Week 3b 13 31 14 4 10 17 5 16 32 18 4 29 5 1 199 14.85 14.25 10.50 11.64 108.72 18.99 82.12 97.21 11.97 16.50 29.59 69.73 51.15 52.55 549.45 1539.00 871.50 174.60 6849.61 1120.35 2299.36 3985.61 1627.92 825.00 621.39 6345.79 869.55 262.75 27,941.89 Public-sector per-dose price (US$)c,d Total costs of each vaccine for the three weeks (US$)d
Table 3 The number of doses, types, and price-per-dose of vaccines provided to refugee children at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic).a Vaccine
Diphtheria–tetanus–acellular pertussis (DTaP) Hepatitis A Hepatitis B (Hep B) Haemophilus influenzae type b (Hib) Human papillomavirus Measles–mumps–rubella Meningococcal Pneumococcal Inactivated poliovirus (IPV) Tetanus–diphtheria Tetanus–diphtheria–acellular pertussis Varicella DTaP–Hep B–IPV DTaP–Hib–IPV Total
a b c d
16 42 41 6 31 24 13 14 61 25 6 39 6 1 325
Children: 0–18 years old. Week 1: February 28–March 4, 2011; Week 2: April 4–8, 2011; Week 3: April 11–15, 2011. Data were extracted from the CDC vaccine price list dated April 11, 2011 (one that is close to the end of study period) [19]. Prices and costs are in 2011 dollars.
Table 4 Costs per dose for refugee vaccination at Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic)—from the perspective of United States federal government. Cost categories Cost (US$)a Adult refugees Average cost of any dose of vaccine costsb Administration reimbursement costsc Total
a
Refugee children $32.77 $9.68e $42.45 $37.06 $9.68e $46.74
$32.77 $8.00d $40.77
Costs are in 2011 dollars. b The estimates were the weighted average costs of vaccine products provided during the study period of three weeks. c Due to the complexity of reimbursement payers, the initial administrative payment for adult vaccines was lower than the payment for 2nd or 3rd doses during the subsequent visit. d The amount is reimbursed by the State of Georgia Refugee Health Program for the initial dose of immunization. e The federal government’s share of Medicaid reimbursement for pediatric vaccines and subsequent doses of adult vaccines (65.33% of $14.81 that the DeKalb clinic receives from Medicaid) [15]. Table 5 Costs for refugee vaccination for the first dose at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic)—from the perspective of DeKalb clinic. Cost categories Cost (US$)a Week 1b Medical-needs labor costs for the first dosec Operational labor costs per refugee associated with vaccination processd Facility-related overhead costse Total costs
a b
Week 2b 6.13 3.52 2.85 12.49
Week 3b 6.13 4.56 3.15 13.84
Average of the three weeks 6.13 3.68 2.89 12.70
6.13 2.96 2.68 11.77
Costs are in 2011 dollars. Week 1: February 28–March 4, 2011; Week 2: April 4–8, 2011; Week 3: April 11–15, 2011. c It was calculated by multiplying the estimated clinical time for the first dose (9.3 min) by weighted average compensation of medical-needs labor (Appendix C, Table C1). d Operational labor time associated with vaccination process was allotted based on the percentage of the number of vaccinated refugees relative to the total number of refugees cycling through the DeKalb clinic. The allotted operational labor time was multiplied by weighted average compensation of operational labor (Appendix C, Table C1). e 30% of the sum of medical-needs and operational labor costs. Table 6 Results one-way sensitivity analysis on vaccination costs for the first dose from the perspective of the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). Condition Percentage of time attributed to the vaccination process for the operational labor Percentage of non-wage benefits relative to wages Percentage of overhead costs relative to labor costs
a
Parameter range See the bottom row of Table 1 26% 50% 50% 100%
Average vaccination cost at the DeKalb clinic (min, max) (US$)a 9.48 (9.37, 9.54) 11.60 (10.75, 12.64) 13.81 (12.80, 15.05) 14.71 (13.64, 16.03) 19.62 (18.18, 21.38)
Costs are in 2011 dollars.
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
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4. Discussion Understanding the resources used by state/local and federal governments to vaccinate refugees is crucial. The perspective of the state/local level health department was necessary to understand what resources are currently used and whether or not resource costs are covered by the reimbursements. The federal government perspective was included because ultimately, the federal government funds most domestic refugee medical care. The results showed that the average cost to the DeKalb clinic for labor and facility-related overhead associated with the administration of the first dose of vaccine to refugees was $12.70. On a per-dose basis, reimbursement by Georgia Medicaid ($14.81) covers the average clinic administrative costs, while SRHP reimbursement ($8.00) does not. However, it is highly likely that total reimbursements covered total clinic administrative costs because the majority of vaccine doses were reimbursed at the higher Georgia Medicaid rate, i.e., all pediatric vaccines, and second and third doses in adult vaccine series. In addition, the first dose of vaccine cost more than additional doses administered at the same time as the first dose (3.1 min for each additional dose as opposed to 9.3 min for the first dose). The absolute cost of medical-needs labor increased with additional doses, but at a decreasing rate. As a result, vaccination was a break-even or slightly positive costrevenue structure at the DeKalb clinic. These results are slightly different from the results of published studies that find that in private medical practices, Medicaid payments frequently do not cover the practice costs to vaccinate publicly insured (Medicaid) patients [4–6,11]. This is problematic because some states use private medical practices to provide refugee medical care, e.g., Minnesota. There are study limitations. Our state/local cost and labor time estimates were solely based on the data from the DeKalb clinic. The programs that administer initial refugee medical screenings are very different from state to state. Further, some states support large numbers of refugees, while other states resettle very few or no refugees. Any average cost of refugee vaccination has the potential to misrepresent some states and, at the same time, no one state can represent other states. In addition, the data were collected for three weeks in spring 2011, and were not adjusted for seasonality. The DeKalb clinic is intent on continuing to fully vaccinate refugees, and that decision is consistent with our conclusion that total vaccine reimbursements outweigh vaccination process costs. This decision is also in line with the understanding that vaccinated populations are critical to the maintenance of public health in the United States. Further, the continued compliance with ACIP and CDC vaccination recommendations is of great benefit to refugees individually and to the communities where they settle. More research needs to be done to evaluate the cost structure of refugee vaccination in other states to better understand variations in refugee resettlement. Acknowledgments We thank Mark Messonnier and Pascale Wortley for their thoughtful review of this manuscript and the staff members, especially Eve Calhoun, at the Board of Health Refugee Services, DeKalb county, Georgia for their supports during the site visits. The article reflects work done while Kenji Adachi was at the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of these authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.vaccine. 2012.08.016.
References
[1] U.S. Department of State, U.S. Department of Homeland Security, U.S. Department of Health and Human Services. Proposed refugee admissions for fiscal year 2012; 2011. [2] Measles among U.S.-bound refugees from Malaysia—California, Maryland, North Carolina, and Wisconsin, August–September 2011. MMWR Morb Mortal Wkly Rep 2011;60(37):1281–2. [3] Coleman MS, Garbat-Welch L, Burke H, Weinberg M, Humbaugh K, Tindall A, et al. Direct costs of a single case of refugee-imported measles in Kentucky. Vaccine 2012;30(2):317–21. [4] Coleman MS, Fontanesi J, Meltzer MI, Shefer A, Fishbein DB, Bennett NM, et al. Estimating medical practice expenses from administering adult influenza vaccinations. Vaccine 2005;23(7):915–23. [5] Coleman MS, Lindley MC, Ekong J, Rodewald L. Net financial gain or loss from vaccination in pediatric medical practices. Pediatrics 2009;124(Suppl. 5):S472–91. [6] Yoo BK, Szilagyi PG, Schaffer SJ, Humiston SG, Rand CM, Albertin CS, et al. Cost of universal influenza vaccination of children in pediatric practices. Pediatrics 2009;124(Suppl. 5):S499–506. [7] Freed GL, Clark SJ, Cowan AE, Coleman MS. Primary care physician perspectives on providing adult vaccines. Vaccine 2011;29(9):1850–4. [8] Effler PV, Chu C, He H, Gaynor K, Sakamoto S, Nagao M, et al. Statewide schoollocated influenza vaccination program for children 5–13 years of age, Hawaii, USA. Emerg Infect Dis 2010;16(February (2)):244–50. [9] Hull HF, Frauendienst RS, Gundersen ML, Monsen SM, Fishbein School-based influenza immunization. Vaccine 2008;26(34): DB. 4312–3. [10] Schmier J, Li S, King Jr JC, Nichol K, Mahadevia PJ. Benefits and costs of immunizing children against influenza at school: an economic analysis based on a large-cluster controlled clinical trial. Health Aff (Millwood) 2008;27(March–April (2)):w96–104. [11] Glazner JE, Beaty BL, Pearson KA, Berman S. The cost of giving childhood vaccinations: differences among provider types. Pediatrics 2004;113(6): 1582–7. [12] LeBaron CW, Rodewald L, Humiston S. How much time is spent on wellchild care and vaccinations? Arch Pediatr Adolesc Med 1999;153(11): 1154–9. [13] Fontanesi J, De Guire M, Holcomb K, Sawyer MH. The cost to immunize during well-child visits. Am J Med Qual 2001;16(6):196–201. [14] Centers for Disease Control and Prevention. Recommended adult immunization schedule – United States, 2011. MMWR 2011;60(4):1–4. [15] US Department of Health and Human Services, Office of the Secretary. Federal financial participation in state assistance expenditures; federal matching shares for medicaid, the children’s health insurance program, and aid to needy aged, blind, or disabled persons for October 1, 2010 through September 30, 2011. Federal Register 2009;74(227):62315–7. [16] Georgia Department of Community Health Division of Public Health. State of Georgia refugee health guidelines manual 2009–2010. [17] Centers for Disease Control and Prevention. Vaccines for children program (VFC). Available from: http://www.cdc.gov/vaccines/programs/vfc/default. htm [cited August 2011]. [18] Centers for Disease Control and Prevention. Immunization grant program (Section 317). Available from: http://www.cdc.gov/vaccines/ programs/vfc/downloads/grant-317.pdf [cited August 2011]. [19] Centers for Disease Control and Prevention. CDC Vaccine price list. Available from: http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm [cited August 2011]. [20] Bureau of Labor Statistics. Occupational Employment Statistics. Occupational employment and wages, May 2010. Available from: http://www.bls.gov/oes/ [cited August 2011]. [21] Congressional Budget Office. Characteristics and pay of federal civilian employees. Washington, DC: Congressional Budget Office, 2007. [22] Bureau of Labor Statistics. Consumer price index; 2011. Available from: http://www.bls.gov/cpi/ [cited August 2011]. [23] Glazner JE, Beaty B, Berman S. Cost of vaccine administration among pediatric practices. Pediatrics 2009;124(Suppl. 5):S492–8. [24] Pellissier JM, Coplan PM, Jackson LA, May JE. The effect of additional shots on the vaccine administration process: results of a time-motion study in 2 settings. Am J Manag Care 2000;6(9):1038–44. [25] Kravitz RL, Helms LJ, Azari R, Antonius D, Melnikow J. Comparing the use of physician time and health care resources among patients speaking English, Spanish, and Russian. Med Care 2000;38(7):728–38. [26] U.S. Department of Labor, Division of Cost Determination, Office of Acquisition Management Services Business Operations Center. A guide for indirect cost rate determination; 2011. [27] United States Agency International Development. Best practices guide for indirect costing. Available from: http://transition.usaid.gov/business/ regulations/BestPractices.pdf. [cited August 2011]. [28] United States Government Accountability Office. Treatment and reimbursement of indirect costs vary among grants, and depend significantly on federal, state, and local government practices; 2010. [29] Issel LM. Health program planning and evaluation: a practical, systematic approach for community health. 2nd ed. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2009.
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Contents lists available at SciVerse ScienceDirect
Vaccine
journal homepage: www.elsevier.com/locate/vaccine
Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia
Kenji Adachi a,∗ , Margaret S. Coleman b , Christopher de la Motte Hurst b , Monica L. Vargas c , Alawode Oladele d , Michelle S. Weinberg b
a
Bayer Yakuhin, Ltd., 4-9, Umeda 2-chome, Kita-ku, Osaka 530-0001, Japan Centers for Disease Control and Prevention, Division of Global Migration and Quarantine, MS E-03 1600 Clifton Road, Atlanta, GA 30333, United States Georgia Department of Public Health, Division of Health Protection, 40 Pryor Street, Atlanta, GA 30303, United States d DeKalb County Board of Health, Refugee Health Program, 445 Winn Way, Decatur, GA 30030, United States
b c
a r t i c l e
i n f o
a b s t r a c t
Background: Approximately 70,000 refugees are resettled to the United States each year. Providing vaccination to arriving refugees is important to both reduce the health-related barriers to successful resettlement, and protect the health of communities where refugees resettle. It is crucial to understand the process and resources expended at the state/local and federal government levels to provide vaccinations to refugees resettling to the United States. Objectives: We estimated costs associated with delivering vaccines to refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). Methods: Vaccination costs were estimated from two perspectives: the federal government and the DeKalb clinic. Data were collected at the DeKalb clinic regarding resources used for vaccination: staff numbers and roles; type and number of vaccine doses administered; and number of patients. Clinic costs included labor and facility-related overhead. The federal government incurred costs for vaccine purchases and reimbursements for vaccine administration. Results: The DeKalb clinic average cost to administer the first dose of vaccine was $12.70, which is lower than Georgia Medicaid reimbursement ($14.81), but higher than the State of Georgia Refugee Health Program reimbursement ($8.00). Federal government incurred per-dose costs for vaccine products and administrative reimbursement were $42.45 (adults) and $46.74 (children). Conclusions: The total costs to the DeKalb clinic for administering vaccines to refugees are covered, but with little surplus. Because the DeKalb clinic ‘breaks even,’ it is likely they will continue to vaccinate refugees as recommended by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices. © 2012 Elsevier Ltd. All rights reserved.
Article history: Received 27 April 2012 Received in revised form 25 July 2012 Accepted 8 August 2012 Available online xxx Keywords: Cost analysis Refugees Vaccine reimbursement
1. Introduction Approximately 70,000 refugees are resettled to the United States annually [1]. Before departing overseas locations, refugees receive a pre-departure medical screening that includes few, if any, vaccines. Refugees in camps (as opposed to urban areas), primarily young children, receive some vaccines through the World Health Organization’s Expanded Programme on Immunization. However, this vaccine package does not include all vaccines recommended
∗ Corresponding author. Tel.: +1 404 639 7023; fax: +1 404 639 4441. E-mail addresses: [email protected] (K. Adachi), [email protected] (M.S. Coleman), [email protected] (C. de la Motte Hurst), [email protected] (M.L. Vargas), [email protected] (A. Oladele), [email protected] (M.S. Weinberg). 0264-410X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2012.08.016
for children in the United States, and provides very few adult vaccines. Further, implementation varies depending on camp location and refugee age. While rare, several vaccine-preventable disease outbreaks have occurred in U.S.-bound refugees. These outbreaks have a negative impact, delaying refugee resettlement [2]. In addition, the importation of even one case of any vaccine-preventable disease creates a domestic exposure risk to unvaccinated people. These events require costly public health responses to isolate and mitigate the risk of further domestic transmission [3]. After arrival in the United States, refugees are vaccinated during initial medical screenings, usually conducted 1–3 months after resettlement. Financing of vaccine purchases, vaccine administration, and medical screening is complex and is comprised of several mechanisms, Vaccines for Children (VFC), Medicaid, and the federally funded but state-administered Refugee Medical Assistance
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
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program. We conducted an observational investigation that estimated costs of vaccinating refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). DeKalb clinic costs were then compared with likely payments from all sources to determine whether clinic expenditures were covered by reimbursements. Our study is unique in several regards. To the best of our knowledge, there are no published studies examining the vaccination process for both children and adults. Previous studies focus on either pediatric or adult vaccinations [4–6]. The DeKalb clinic also delivers larger numbers of adult vaccines than reported by other medical practices [7]. Finally, perhaps the most important unique characteristic is that there are no other studies of the economics of clinic-level vaccination that include observed numbers of both patients flowing through a clinic and vaccine doses administered. Currently published studies of large-scale influenza vaccination pilot projects or initiatives have observed numbers of doses and patients, but these are one-time events, not established medical practices [8–10]. Publications that estimate costs and effort of vaccination in established medical practices either model or assume total patient flow and numbers of doses of vaccine administered [4–6,11–13]. Our unparalleled access to DeKalb clinic records provided directly observed data of total numbers of patients and vaccine doses, and allowed for more accurate estimates of labor time and associated costs. This study was initiated in the Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC) because of an interest in comparing overseas vs. domestic vaccination programs. In a subsequent manuscript we will report the overseas portion of the ongoing study to analyze refugee vaccination options. 2. Methods Approximately 2000–4000 refugees arrive in Georgia annually; 90% receive their initial medical screening and vaccines at the DeKalb clinic. This investigation was determined to be nonresearch by CDC. 2.1. Study perspectives Most domestic costs of vaccinating refugees are incurred by two stakeholders: the federal government for vaccine purchases and administrative reimbursements; and the local medical clinics that vaccinate refugees during their initial domestic medical screening. Vaccination costs were estimated from the perspectives of the federal government and the DeKalb clinic. 2.1.1. United States federal government and reimbursement structure From the federal government perspective, costs of vaccinating refugees include funding to purchase vaccine products (e.g., measles–mumps–rubella (MMR)) and funding to reimburse for vaccination administration. Federal funds are distributed to the state of Georgia through a complex of funding vehicles. Vaccine products are provided free of charge to the DeKalb clinic, but are paid through: VFC; Section 317 grants program; Medicaid; or the Cash and Medical Assistance (CMA) program. Georgia uses a mix of funding to purchase vaccines and distribute them to the DeKalb clinic while vaccination administration reimbursements are paid through the Georgia Medicaid program and the State of Georgia Refugee Health Program (SRHP). Georgia Medicaid (for children, PeachCare) and SRHP pay different levels of vaccine administration reimbursements and pay for different numbers of vaccines and different vaccine-eligible populations. SRHP reimburses only for adults (21 years+) and for the first dose of 6 vaccines. SRHP
does not reimburse for the second or third doses in vaccine series requiring multiple doses over time. Series are hepatitis A (2 doses), hepatitis B (3 doses), MMR (1 or 2 doses), tetanus–diphtheria (a booster every 10 years)/tetanus–diphtheria–acellular pertussis (1 dose), pneumococcal (1 or 2 doses), and varicella (2 doses) [14]. Georgia Medicaid reimburses for administration of every dose of all pediatric vaccines and for second and third doses of adult vaccine series. SRHP reimburses adult vaccination administration at $8 per dose/injection to a maximum of $48 per refugee. Medicaid reimburses a $14.81 payment per dose/injection for subsequent doses of adult vaccines and for all pediatric vaccine doses with no upper limit. SRHP is funded by the federal government through the CMA. The funding for Georgia Medicaid is shared between the federal and state governments at contributions of 65.33% and 34.67%, respectively [15]. VFC, Section 317, CMA, and SRHP programs are briefly described in supplemental materials (Appendix A). 2.1.2. Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic) The DeKalb clinic does not pay for vaccine products, but does incur labor and facility-related overhead costs associated with the vaccination process. The process includes ordering, storing, maintaining the cold-chain, vaccinating and educating patients about vaccine medical benefits and risks. As part of the DeKalb clinic perspective, we compared the data on Medicaid and SRHP reimbursement with the labor and overheard cost estimates to determine whether reimbursements cover the costs of the vaccination process [4–6]. The DeKalb clinic follows the Advisory Committee on Immunization Practices (ACIP) childhood and adult vaccination recommendations except for hepatitis B virus vaccination. In addition to routine ACIP recommendations, the Georgia Department of Community Health, Division of Public Health, recommends hepatitis B virus vaccine for all refugee adults who do not test positive for hepatitis B virus infection [16]. 2.2. Primary data Primary data regarding clinic operations and resource use were collected during visits to the DeKalb clinic. During one visit two investigators observed program activities, obtained employee information, such as the number of clinic staff and their titles and roles, and collected data about the numbers of vaccinations administered and patient visits from clinic superbills (dated February 28–March 4, 2011). Superbills are a form used in medical facilities to record services provided to patients during a visit. At the DeKalb clinic, patients who are vaccinated receive two superbills, one for the clinic visit and one for vaccine administration. The vaccine administration superbill records the type and number of doses of vaccines administered. In addition to the data from observation and superbills collected during our initial visit, we also collected data from two additional weeks’ worth of superbills (April 4–8 and 11–15, 2011) to document the types and numbers of vaccines over a longer period of time. We made a second visit to the DeKalb clinic to verify details of our data collection with the staff (Appendix B). 2.3. Vaccine product costs The vaccine product costs were estimated using VFC prices. The federal government negotiates vaccine product prices with manufacturers for the VFC program [17]. The federal government then provides VFC funding that can only be designated for vaccine purchases and Section 317 block grant funding to cover additional vaccines (e.g., adult vaccines) or program costs to states. States determine what types of, and how many doses of, vaccines to purchase at the listed VFC prices, and use VFC and 317 funds to make
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these purchases. About half of all states add state and local funding to federal funding to round out vaccine purchases. States then distribute vaccines to VFC-participating medical practices; the DeKalb clinic receives vaccines free of charge from Georgia [17,18]. Refugee demographics and circumstances, e.g., age and whether or not they have immunization records, determine the vaccines received by each refugee. To obtain representative estimates for groups of refugees, we calculated the average costs of vaccine products provided during the three-week study period in two steps. First, the total cost of vaccines was estimated by multiplying the number of doses of each vaccine (pediatric or adult) by its VFC price dated April 11, 2011 [19]. Second, the total costs of vaccines were divided by the total number of vaccine doses provided over the study period. 2.4. Employee compensation To determine the cost of DeKalb clinic labor, we used wage data from the Bureau of Labor Statistics’ Occupational Employment Statistics (OES) [20] and DeKalb clinic records of numbers of employees and titles/roles (Appendix C, Table C1). Thirty-eight percent was added to wages to calculate total employee compensation [21]. Compensation was further adjusted for inflation using the consumer price index for medical care services [22]. 2.5. Modeling labor costs All medical practices, including the DeKalb clinic, employ two types of labor. In general terms, medical-needs labor time varies with the numbers of protocols or services and complexity of medical care, while operational labor time varies with the total number of patients and is approximately equal per patient [4–6]. 2.5.1. Medical-needs labor Staff providing direct medical services was categorized as medical-needs labor and their labor time-per-patient varies with the complexity and numbers of medical services, e.g., a patient getting several vaccines takes more nursing time than a patient getting one vaccine. In other publications, this type of labor is usually labeled “clinical labor” [4–6]. However, at the DeKalb clinic, interpreters are critical to medical care, but would not normally be thought of as clinicians, so we used the term medical-needs labor in this particular medical clinic setting. Medical-needs labor time associated with vaccination included the tasks of vaccine preparation, injection, record keeping, education, clean up, and language interpretation. The time for these tasks, except for interpretation, was calculated using an average of several published clinical times [11,12,23,24]. Average clinical time for first and subsequent doses was adjusted upward 27% to account for interpreter labor time [25]. The calculated medical-needs labor time was multiplied by weighted average staff compensation to estimate medical-needs labor cost for the first dose (Appendix C, Table C1). 2.5.2. Operational labor Operational labor refers to staff providing services per-refugee, such as patient check-in, superbill data entry, arrangement of appointments with refugee supporting organizations, or immunization registry. The study does not include labor time for follow up and missed appointments because data was not available. Operational labor time is an average-per-patient; for example, pulling medical charts takes approximately the same average amount of time per patient regardless of the complexity of care the patient receives. Operational labor time in the vaccination process was calculated by multiplying the total operational labor time per refugee by the percentage of time attributed to vaccination. This percentage was
estimated as the proportion of the number of vaccinated refugees relative to the total number of refugees cycling through the DeKalb clinic. The operational labor time associated with the vaccination process per refugee was multiplied by a weighted average staff compensation to estimate costs for this labor category (Appendix C, Table C1). 2.6. Overhead costs Overhead costs are defined as all facility-associated expenses other than labor compensation, such as utilities, malpractice insurance, nonmedical and medical supplies, and equipment (e.g., refrigerator to store vaccines). Overhead was estimated as 30% of the total labor costs [26–29]. 2.7. Sensitivity analysis Three one-way sensitivity analyses were conducted to examine the effects of the different assumptions on the estimated cost from the DeKalb clinic perspective: • Changed the model calculation for operational labor from the percentage of the number of vaccinated refugees relative to the total number of refugees to the percentage of time that medicalneeds labor devoted to vaccinating refugees relative to the total medical-needs labor time. (This alternative method to apportion operational labor time for the vaccination process was the primary method used in the overseas portion of the study mentioned in Section 1.) • Changed the percentage of wages used to calculate non-wage benefits from 38% to 26 and 50% [21]. • Changed the percentage of overhead relative to total labor costs from 30% to 50 and 100%. 3. Results 3.1. Labor time estimates The medical-needs labor time for vaccination was estimated at 9.3 min for the first dose and 3.0 min per each additional dose. By comparison, previous studies estimated 11 min for scheduled visits of adult influenza vaccination [4] and 6–7 min for other various vaccination settings in pediatric clinics (e.g., vaccination during well-child visits) [11,23]. The operational labor time per patient associated with the vaccination process was calculated from 7.3 to 11.3 min (9.1 min on average) for the three-week study period. 3.2. Number of vaccine doses and patients (Table 1) Over the three-week period of time for which primary data was collected, the total number of vaccine doses administered ranged from 422 to 668, and the total number of patients ranged from 549 to 811. Not every patient was vaccinated, but for those who did receive vaccines, the number of doses provided was approximately proportional to the number of vaccinated patients. Each vaccinated patient received an average of 2.01–2.33 vaccine doses during the three weeks of primary data. 3.3. Costs for vaccines The majority of adult vaccinations were for hepatitis B, varicella, MMR, and tetanus–diphtheria/tetanus–diphtheria–acellular pertussis (Table 2). The weighted average per-dose cost of adult vaccine products was estimated at $32.77.
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K. Adachi et al. / Vaccine xxx (2012) xxx–xxx Week 1a Week 2a Week 3a Average of the three weeks 251 260 512 236 2.16 671 35.3% 11.5%
Table 1 The number of doses of vaccines provided and the number of patients at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). Description The number of vaccine doses provided Childrenb Adultsb Total (children + adults) The number of patients/superbills for vaccine administrationc Average number of doses of vaccines per vaccinated patient/superbillc,e The total number of patients/superbills issued at the DeKalb clinicc The percentage of the number of vaccinated patients relative to the total number of patients The percentage of medical-needs labor time for refugee vaccination relative to the total medical-needs labor timef
a b
325 343 668 286d 2.33 811 35.3% 14.5%
230 215 445 221 2.01 654 33.8% 10.4%
199 223 422 202 2.09 549 36.8% 9.7%
Week 1: February 28–March 4, 2011; Week 2: April 4–8, 2011; Week 3: April 11–15, 2011. Children: 0–18 years old; adults: 19 years old and over. c A superbill is a form used by most healthcare providers to record the services provided to each patient. It is also used to bill for reimbursement from public and private insurers. At the DeKalb clinic, patients who are vaccinated receive two superbills, one for the clinic visit and one for vaccine administration. Because superbills are issued for every visit to every patient, we considered the number of superbills a proxy for the number of patients. d The information was not collected for Week 1. To derive this number, we multiplied the total number of patients in Week 1 by the average percentage of the number of vaccine administration superbills relative to the total number of patients for the other two weeks of the study period (Appendix B). e The average number of doses of vaccines per superbill was calculated by dividing total number of vaccine doses (the sum of vaccine doses for refugee children and adults) by the number of superbills for vaccine administration. f The percentages were estimated in two steps. First, overall medical-needs labor time devoted to refugee vaccination in each week was calculated based on the estimated clinical time of vaccination (i.e., 9.3 min for the first dose and 3.1 min for each additional dose) and the number of vaccine doses provided. Second, the overall medical-needs labor time devoted to refugee vaccination was divided by the total medical-needs labor time in each week (i.e., the number of full-time equivalent employees multiplied by 2400 work-minutes a week).
The top three pediatric vaccines, in terms of the number of doses provided, were inactivated poliovirus, hepatitis A, and varicella (Table 3). The weighted average per-dose cost of pediatric vaccine products was estimated at $37.06. 3.4. Costs for refugee vaccination 3.4.1. Federal government (Table 4) Given that Georgia receives 65.33% of its Medicaid funding through federal medical assistance [15], the federal share of vaccine administration reimbursement was set at $9.68 per dose (or 65.33% of $14.81 per dose). The initial and subsequent per-dose vaccine costs for adults were estimated at $40.77 and $42.45, respectively. The per-dose cost for pediatric vaccines was $46.74. 3.4.2. Board of Health Refugee Services, DeKalb county, Georgia (Table 5) From the perspective of the DeKalb clinic, the average labor and overhead cost for the first dose of vaccine was $12.70, with a range of $11.77–13.84. On average, medical-needs labor, operational labor, and facility-related overhead costs accounted for $6.13 (48%), $3.68 (29%), and $2.89 (23%), respectively. The results indicate that the Medicaid reimbursement of $14.81 covers the costs
for the first dose of vaccine provided to refugees during the three weeks, but the SRHP reimbursement of $8 does not. 3.5. Sensitivity analysis (Table 6) From the perspective of the DeKalb clinic, the primary analysis yielded a vaccination cost for the first vaccine dose of $12.70. • Changing the method of calculating the operational labor time from (a) to (b) below resulted in decreasing the average vaccination cost from $12.70 to $9.48. (a) The percentage of the number of vaccinated refugees relative to the total number of refugees cycling through the DeKalb clinic varied from 33.8% to 36.8% (35.3% as average) (Table 1). (b) The percentages of vaccination time relative to the total medical-needs labor time in each week varied from 9.7% to 14.5% (11.5% as average) (Table 1). • Changing the percentage of wages added for non-wage benefits from 38% to 26 and 50% resulted in average vaccination costs of $11.60 and $13.81, respectively. • Changing the percentage of overhead costs relative to labor costs from 30% to 50 and 100% resulted in increasing the average vaccination costs from $12.70 to $14.71 and $19.62, respectively.
Table 2 The number of doses, types, and price-per-dose of vaccines provided to adult refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic).a Vaccine Doses per week Week 1b Hepatitis B Human papillomavirus Measles–mumps–rubella Pneumococcal Tetanus–diphtheria Tetanus–diphtheria–acellular pertussis Varicella Total
a b c d
Public-sector per-dose price (US$)c , d Week 2b 69 0 39 0 40 22 45 215 Week 3b 59 0 41 2 47 27 47 223 28.00 89.17 33.61 20.57 13.82 26.25 55.36
Total costs of each vaccine for the three weeks (US$)d
90 1 54 5 53 45 95 343
6104.00 89.17 4504.28 143.98 1934.80 2467.50 10,353.07 25,596.80
Adult: 19 years old and over. Week 1: February 28–March 4, 2011; Week 2: April 4–8, 2011; Week 3: April 11–15, 2011. Data are extracted from the CDC vaccine price list dated April 11, 2011 (one that is close to the end of the study period) [19]. Prices and costs are in 2011 dollars.
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
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K. Adachi et al. / Vaccine xxx (2012) xxx–xxx 5 Doses per week Week 1b Week 2b 8 35 28 5 22 18 10 11 43 7 11 23 6 3 230 Week 3b 13 31 14 4 10 17 5 16 32 18 4 29 5 1 199 14.85 14.25 10.50 11.64 108.72 18.99 82.12 97.21 11.97 16.50 29.59 69.73 51.15 52.55 549.45 1539.00 871.50 174.60 6849.61 1120.35 2299.36 3985.61 1627.92 825.00 621.39 6345.79 869.55 262.75 27,941.89 Public-sector per-dose price (US$)c,d Total costs of each vaccine for the three weeks (US$)d
Table 3 The number of doses, types, and price-per-dose of vaccines provided to refugee children at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic).a Vaccine
Diphtheria–tetanus–acellular pertussis (DTaP) Hepatitis A Hepatitis B (Hep B) Haemophilus influenzae type b (Hib) Human papillomavirus Measles–mumps–rubella Meningococcal Pneumococcal Inactivated poliovirus (IPV) Tetanus–diphtheria Tetanus–diphtheria–acellular pertussis Varicella DTaP–Hep B–IPV DTaP–Hib–IPV Total
a b c d
16 42 41 6 31 24 13 14 61 25 6 39 6 1 325
Children: 0–18 years old. Week 1: February 28–March 4, 2011; Week 2: April 4–8, 2011; Week 3: April 11–15, 2011. Data were extracted from the CDC vaccine price list dated April 11, 2011 (one that is close to the end of study period) [19]. Prices and costs are in 2011 dollars.
Table 4 Costs per dose for refugee vaccination at Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic)—from the perspective of United States federal government. Cost categories Cost (US$)a Adult refugees Average cost of any dose of vaccine costsb Administration reimbursement costsc Total
a
Refugee children $32.77 $9.68e $42.45 $37.06 $9.68e $46.74
$32.77 $8.00d $40.77
Costs are in 2011 dollars. b The estimates were the weighted average costs of vaccine products provided during the study period of three weeks. c Due to the complexity of reimbursement payers, the initial administrative payment for adult vaccines was lower than the payment for 2nd or 3rd doses during the subsequent visit. d The amount is reimbursed by the State of Georgia Refugee Health Program for the initial dose of immunization. e The federal government’s share of Medicaid reimbursement for pediatric vaccines and subsequent doses of adult vaccines (65.33% of $14.81 that the DeKalb clinic receives from Medicaid) [15]. Table 5 Costs for refugee vaccination for the first dose at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic)—from the perspective of DeKalb clinic. Cost categories Cost (US$)a Week 1b Medical-needs labor costs for the first dosec Operational labor costs per refugee associated with vaccination processd Facility-related overhead costse Total costs
a b
Week 2b 6.13 3.52 2.85 12.49
Week 3b 6.13 4.56 3.15 13.84
Average of the three weeks 6.13 3.68 2.89 12.70
6.13 2.96 2.68 11.77
Costs are in 2011 dollars. Week 1: February 28–March 4, 2011; Week 2: April 4–8, 2011; Week 3: April 11–15, 2011. c It was calculated by multiplying the estimated clinical time for the first dose (9.3 min) by weighted average compensation of medical-needs labor (Appendix C, Table C1). d Operational labor time associated with vaccination process was allotted based on the percentage of the number of vaccinated refugees relative to the total number of refugees cycling through the DeKalb clinic. The allotted operational labor time was multiplied by weighted average compensation of operational labor (Appendix C, Table C1). e 30% of the sum of medical-needs and operational labor costs. Table 6 Results one-way sensitivity analysis on vaccination costs for the first dose from the perspective of the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic). Condition Percentage of time attributed to the vaccination process for the operational labor Percentage of non-wage benefits relative to wages Percentage of overhead costs relative to labor costs
a
Parameter range See the bottom row of Table 1 26% 50% 50% 100%
Average vaccination cost at the DeKalb clinic (min, max) (US$)a 9.48 (9.37, 9.54) 11.60 (10.75, 12.64) 13.81 (12.80, 15.05) 14.71 (13.64, 16.03) 19.62 (18.18, 21.38)
Costs are in 2011 dollars.
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
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K. Adachi et al. / Vaccine xxx (2012) xxx–xxx
4. Discussion Understanding the resources used by state/local and federal governments to vaccinate refugees is crucial. The perspective of the state/local level health department was necessary to understand what resources are currently used and whether or not resource costs are covered by the reimbursements. The federal government perspective was included because ultimately, the federal government funds most domestic refugee medical care. The results showed that the average cost to the DeKalb clinic for labor and facility-related overhead associated with the administration of the first dose of vaccine to refugees was $12.70. On a per-dose basis, reimbursement by Georgia Medicaid ($14.81) covers the average clinic administrative costs, while SRHP reimbursement ($8.00) does not. However, it is highly likely that total reimbursements covered total clinic administrative costs because the majority of vaccine doses were reimbursed at the higher Georgia Medicaid rate, i.e., all pediatric vaccines, and second and third doses in adult vaccine series. In addition, the first dose of vaccine cost more than additional doses administered at the same time as the first dose (3.1 min for each additional dose as opposed to 9.3 min for the first dose). The absolute cost of medical-needs labor increased with additional doses, but at a decreasing rate. As a result, vaccination was a break-even or slightly positive costrevenue structure at the DeKalb clinic. These results are slightly different from the results of published studies that find that in private medical practices, Medicaid payments frequently do not cover the practice costs to vaccinate publicly insured (Medicaid) patients [4–6,11]. This is problematic because some states use private medical practices to provide refugee medical care, e.g., Minnesota. There are study limitations. Our state/local cost and labor time estimates were solely based on the data from the DeKalb clinic. The programs that administer initial refugee medical screenings are very different from state to state. Further, some states support large numbers of refugees, while other states resettle very few or no refugees. Any average cost of refugee vaccination has the potential to misrepresent some states and, at the same time, no one state can represent other states. In addition, the data were collected for three weeks in spring 2011, and were not adjusted for seasonality. The DeKalb clinic is intent on continuing to fully vaccinate refugees, and that decision is consistent with our conclusion that total vaccine reimbursements outweigh vaccination process costs. This decision is also in line with the understanding that vaccinated populations are critical to the maintenance of public health in the United States. Further, the continued compliance with ACIP and CDC vaccination recommendations is of great benefit to refugees individually and to the communities where they settle. More research needs to be done to evaluate the cost structure of refugee vaccination in other states to better understand variations in refugee resettlement. Acknowledgments We thank Mark Messonnier and Pascale Wortley for their thoughtful review of this manuscript and the staff members, especially Eve Calhoun, at the Board of Health Refugee Services, DeKalb county, Georgia for their supports during the site visits. The article reflects work done while Kenji Adachi was at the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of these authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.vaccine. 2012.08.016.
References
[1] U.S. Department of State, U.S. Department of Homeland Security, U.S. Department of Health and Human Services. Proposed refugee admissions for fiscal year 2012; 2011. [2] Measles among U.S.-bound refugees from Malaysia—California, Maryland, North Carolina, and Wisconsin, August–September 2011. MMWR Morb Mortal Wkly Rep 2011;60(37):1281–2. [3] Coleman MS, Garbat-Welch L, Burke H, Weinberg M, Humbaugh K, Tindall A, et al. Direct costs of a single case of refugee-imported measles in Kentucky. Vaccine 2012;30(2):317–21. [4] Coleman MS, Fontanesi J, Meltzer MI, Shefer A, Fishbein DB, Bennett NM, et al. Estimating medical practice expenses from administering adult influenza vaccinations. Vaccine 2005;23(7):915–23. [5] Coleman MS, Lindley MC, Ekong J, Rodewald L. Net financial gain or loss from vaccination in pediatric medical practices. Pediatrics 2009;124(Suppl. 5):S472–91. [6] Yoo BK, Szilagyi PG, Schaffer SJ, Humiston SG, Rand CM, Albertin CS, et al. Cost of universal influenza vaccination of children in pediatric practices. Pediatrics 2009;124(Suppl. 5):S499–506. [7] Freed GL, Clark SJ, Cowan AE, Coleman MS. Primary care physician perspectives on providing adult vaccines. Vaccine 2011;29(9):1850–4. [8] Effler PV, Chu C, He H, Gaynor K, Sakamoto S, Nagao M, et al. Statewide schoollocated influenza vaccination program for children 5–13 years of age, Hawaii, USA. Emerg Infect Dis 2010;16(February (2)):244–50. [9] Hull HF, Frauendienst RS, Gundersen ML, Monsen SM, Fishbein School-based influenza immunization. Vaccine 2008;26(34): DB. 4312–3. [10] Schmier J, Li S, King Jr JC, Nichol K, Mahadevia PJ. Benefits and costs of immunizing children against influenza at school: an economic analysis based on a large-cluster controlled clinical trial. Health Aff (Millwood) 2008;27(March–April (2)):w96–104. [11] Glazner JE, Beaty BL, Pearson KA, Berman S. The cost of giving childhood vaccinations: differences among provider types. Pediatrics 2004;113(6): 1582–7. [12] LeBaron CW, Rodewald L, Humiston S. How much time is spent on wellchild care and vaccinations? Arch Pediatr Adolesc Med 1999;153(11): 1154–9. [13] Fontanesi J, De Guire M, Holcomb K, Sawyer MH. The cost to immunize during well-child visits. Am J Med Qual 2001;16(6):196–201. [14] Centers for Disease Control and Prevention. Recommended adult immunization schedule – United States, 2011. MMWR 2011;60(4):1–4. [15] US Department of Health and Human Services, Office of the Secretary. Federal financial participation in state assistance expenditures; federal matching shares for medicaid, the children’s health insurance program, and aid to needy aged, blind, or disabled persons for October 1, 2010 through September 30, 2011. Federal Register 2009;74(227):62315–7. [16] Georgia Department of Community Health Division of Public Health. State of Georgia refugee health guidelines manual 2009–2010. [17] Centers for Disease Control and Prevention. Vaccines for children program (VFC). Available from: http://www.cdc.gov/vaccines/programs/vfc/default. htm [cited August 2011]. [18] Centers for Disease Control and Prevention. Immunization grant program (Section 317). Available from: http://www.cdc.gov/vaccines/ programs/vfc/downloads/grant-317.pdf [cited August 2011]. [19] Centers for Disease Control and Prevention. CDC Vaccine price list. Available from: http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm [cited August 2011]. [20] Bureau of Labor Statistics. Occupational Employment Statistics. Occupational employment and wages, May 2010. Available from: http://www.bls.gov/oes/ [cited August 2011]. [21] Congressional Budget Office. Characteristics and pay of federal civilian employees. Washington, DC: Congressional Budget Office, 2007. [22] Bureau of Labor Statistics. Consumer price index; 2011. Available from: http://www.bls.gov/cpi/ [cited August 2011]. [23] Glazner JE, Beaty B, Berman S. Cost of vaccine administration among pediatric practices. Pediatrics 2009;124(Suppl. 5):S492–8. [24] Pellissier JM, Coplan PM, Jackson LA, May JE. The effect of additional shots on the vaccine administration process: results of a time-motion study in 2 settings. Am J Manag Care 2000;6(9):1038–44. [25] Kravitz RL, Helms LJ, Azari R, Antonius D, Melnikow J. Comparing the use of physician time and health care resources among patients speaking English, Spanish, and Russian. Med Care 2000;38(7):728–38. [26] U.S. Department of Labor, Division of Cost Determination, Office of Acquisition Management Services Business Operations Center. A guide for indirect cost rate determination; 2011. [27] United States Agency International Development. Best practices guide for indirect costing. Available from: http://transition.usaid.gov/business/ regulations/BestPractices.pdf. [cited August 2011]. [28] United States Government Accountability Office. Treatment and reimbursement of indirect costs vary among grants, and depend significantly on federal, state, and local government practices; 2010. [29] Issel LM. Health program planning and evaluation: a practical, systematic approach for community health. 2nd ed. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2009.
Please cite this article in press as: Adachi K, et al. Costs of, and reimbursement for, vaccines: A case study at the Board of Health Refugee Services in DeKalb county, Georgia. Vaccine (2012), http://dx.doi.org/10.1016/j.vaccine.2012.08.016
