Value-based Insurance Design in Connection with Preventive Care Benefits

On February 29, 2011 BIO commented on the design aspects of preventive care benefits in value-based insurance plans.</p>

HHS-OS-2010-002: Request for Information Regarding Value-based Insurance Design in Connection with Preventive Care Benefits

The Biotechnology Industry Organization (BIO) appreciates this opportunity to comment on the design aspects of preventive care benefits in value-based insurance plans. BIO represents more than 1,100 biotechnology companies, academic institutions, state biotechnology centers and related organizations across the United States and in more than 30 other nations. BIO members are involved in the research and development of innovative healthcare, agricultural, industrial and environmental biotechnology products.

BIO membership includes both current and future vaccine developers and manufacturers who have worked closely with the public health community to support policies that help ensure access to innovative and life-saving vaccines for all individuals. We were therefore strongly encouraged by the inclusion of first dollar coverage for preventive services, including immunizations, in Section 2713 of the Affordable Care Act. Immunizations are a simple, safe, and cost-effective method of preventing disease and mitigating the need for hospitalizations and other costly treatments. Their value in preventing negative health outcomes across the life span has been a proven and integral part of our health care system. Requiring health insurers and health plans to provide this coverage without any cost-sharing should help increase adoption of immunizations at all ages but especially those recommended for adults.

The interim final regulations promulgated by the Department of Health and Human Services suggest that health plans that have a network of providers may impose cost-sharing for preventive services if they are delivered by an out-of-network provider. This is of serious concern to BIO as it could hamper vaccination activities at alternative community locations. Facilities such as retail pharmacies, school-based clinics, urgent care centers and other non-physician offices are often the primary vaccination location for adults, including many with underlying medical conditions, who are key targets for immunizations such as influenza, pneumoccocal and herpes zoster (shingles).

BIO recommends that the interim final rules include clear language encouraging value-based design plans to allow the delivery of immunization services outside physician office settings under the same first dollar coverage provisions as applicable within their network. Many state laws allow for the provision of immunization services in complementary, non-physician office settings. Facilitating access to various alternative immunizations sites will help health plans develop an expansive network of locations and providers. For many consumers access to community immunizers is essential for completing the recommended immunization schedule as some providers do not stock a full complement of ACIP-recommended adult vaccines. For example, according to a 2010 study by the RAND Corporation, approximately 17% of seasonal influenza vaccine was administered in retail pharmacies in the 2009-10 season.

We suggest that the Department of Health and Human Services strongly encourage value-based plans to: 1) build networks of providers for immunization services that include a broad array of health care providers and locations allowed by state law to provide such services and 2) allow for specific preventive services such as immunizations at no cost-sharing with out-of-network providers as well. As discussed in the preamble of the interim final regulation, value-based insurance designs should offer consumers a choice of providers and services that offer the best value and quality and access to critical, evidence-based preventive services.

BIO emphasizes that pharmacists, especially in the retail sector, are pivotal to the full implementation of influenza and pneumococcal vaccination programs across the nation. Information from the American Pharmacists Association for 2009 showed that U.S. pharmacists had delivered over 16 million doses of vaccine across all age groups. The convenience and accessibility of their locations has been very important for working adults and seniors. Eliminating cost-sharing for vaccines and their administration will encourage providers to offer and consumers to seek out and receive appropriate immunizations.

Many ACIP-recommended vaccines are designed to prevent diseases that are particularly onerous, such as shingles and pneumonia. Others are significant for those with certain underlying illnesses, such as hepatitis A for those with chronic liver disease. Still others, such as the combination tetanus-diphtheria-pertussis vaccine (Tdap) are very important for parents and caretakers of young infants. BIO is very concerned that failing to provide a mechanism to reduce beneficiaries’ barriers to access vaccines may mean they will not take advantage of those preventive services even when they are included as part of the in-network value-based plan. We ask HHS to work with the designers of value-based plans to ensure their beneficiaries have access to these important, cost-effective vaccines. BIO believes this is consistent with Congressional intent to preserve beneficiary access to preventive services and strongly supports this proposal.

BIO members strongly support provisions that will help ensure access to proven preventive services, such as vaccinations. We look forward to future opportunities to work with the Department to maximize adoption of the preventive services and quality provisions of the Patient Protection and Affordable Care Act.


BIO appreciates the opportunity to comment on how preventive services should be incorporated into value-based plans. We look forward to continuing to work with HHS to address these critical issues in the future. Please feel free to contact me at 202-962-6664 if you have any questions or if we can be of further assistance. Thank you for your attention to this very important matter.

With Sincerest Regards,

Phyllis A. Arthur
Senior Director, Vaccines, Immunotherapeutics and Diagnostics Policy
Biotechnology Industry Organization