As Hospital Prices Soar, a Stitch Tops $500 (Published 2013)
Insurers Aren't Saying Whether They'll Cover Vaccines For Kids If Government Stops Recommending Them
In the wake of the Advisory Committee on Immunization Practices (ACIP) announcing plans to revisit its recommended schedule for childhood vaccinations—a move that has drawn widespread criticism from experts—major insurers have not confirmed whether they'll continue to cover the full cost of routine shots for children.
For 60 years ACIP has provided vaccine guidance to the Centers for Disease Control and Prevention (CDC), including on the timing and dosage of childhood immunizations. Insurers are required to cover the cost of most jabs on the recommended schedule for children. On Wednesday, June 25, ACIP announced it would review the schedule, just weeks after health secretary and longtime anti-vaccine activist Robert F. Kennedy Jr. Replaced the entire committee with his own appointees.
When WIRED then asked 21 of the country's largest health insurance groups whether they would stop providing cost-free coverage of current routine immunizations in the event ACIP stops recommending them, only Blue Shield of California—a company in the Blue Cross Blue Shield Association—confirmed it would continue coverage.
"As a payer our role is to ensure ongoing coverage and access to preventive, evidence-based care, including immunizations," says company spokesperson Mark Seelig. "Therefore, Blue Shield of California is committed to maintaining coverage of immunizations. The decision on whether to receive a vaccine is between our member and their provider."
Other large insurers, including UnitedHealthcare (which provides coverage for 50 million people), Cigna, Kaiser Permanente, Anthem, Humana, and Centene Corporation, did not respond to requests for comment. Blue Cross Blue Shield of Michigan said it had no comment.
Most insurers that did respond said they were keeping an eye on developments in Washington, without indicating whether they would or would not cover vaccines dropped from the recommended schedule.
"Vaccines play an important role in the prevention of more serious illnesses," says Phil Blando, a spokesperson at CVS Health, which owns the insurer Aetna. "We are monitoring any changes the federal government makes to vaccination guidance and eligibility and will evaluate whether coverage adjustments are needed."
Highmark Inc., part of the Blue Cross Blue Shield Association, operating in Pennsylvania, Delaware, West Virginia, and New York, is also waiting to see what decision ACIP reaches. "We are closely monitoring the evolving vaccine discussions occurring in Washington, DC. Various vaccines and immunizations are covered under Highmark's member benefits, with any future coverage considerations to be evaluated as more information becomes available," says spokesperson Aaron Billger.
Bryan Campen, of Health Care Service Corporation—the licensee of Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma, and Texas—notes that no changes have yet been made to the vaccines ACIP recommends or the company's vaccine coverage, but says that the company will "continue to monitor any activity that may impact preventive care recommendations and will communicate any changes to recommendations that may impact standard coverage of preventive services."
Insurers had an eye on changes in ACIP guidance even before the committee announced it would revisit the schedule. "As we navigate an evolving health care landscape, maintaining robust immunization coverage continues to be a top priority for protecting both individual and community health," the industry's trade association, AHIP, said in a June 24 statement, the day before ACIP's announcement.
"We are committed to ongoing coverage of vaccines to ensure access and affordability for this respiratory virus season," the statement continued. "We encourage all Americans to talk to their health care provider about vaccines."
ACIP made headlines in early June when RFK Jr. Fired all 17 of its members and replaced them with eight new appointees. (The HHS secretary appoints the committee's members, but conventionally they serve fixed four-year terms.) These new appointees include Retsef Levi, who has stated—in the face of scientific consensus—that mRNA vaccines are deadly, and Robert Malone, who routinely shares articles about supposed links between cancer and the Covid vaccine, which no credible research has found to exist. Neither Levi nor Malone replied to a request for comment.
Michael A. Ross, another recently appointed committee member, resigned from ACIP during a review of his financial holdings, The New York Times reported on June 24. When introducing his new ACIP appointees in a post on X earlier in June, RFK Jr. Had described Ross as a faculty member at George Washington and Virginia Commonwealth universities—but spokespeople for the universities told NBC News4 that Ross had not taught at either in years. Ross did not reply to a request for comment.
The committee made news again on June 25 when, during its first meeting of the year, it announced it would form a working group to review the recommended immunization schedule for children and teens.
"The number of vaccines that our children and adolescents receive today exceed what children in most other developed nations receive, and what most of us in this room received when we [were] children," ACIP chair Martin Kulldorff said during the meeting.
He noted that the group would examine the "cumulative effect" of the recommended vaccine schedule, including interactions between vaccines, the total number of vaccines given, their timing, and recipients' exposure to vaccine ingredients.
But the process for adding vaccines to the schedule is already rigorous. Before a vaccine can receive FDA licensure, its manufacturer must prove it does not negatively affect the safety or immune response of other vaccines administered at the same time on the schedule, says Paul Offit, director of the Children's Hospital of Philadelphia's Vaccine Education Center.
In addition, "the notion that these vaccines are somehow weakening your immune system or overwhelming your immune system is fanciful," Offit says. Today, children are exposed to fewer viral or bacterial proteins in the first few years of the vaccine schedule than those in earlier generations. When Offit's parents received the smallpox vaccine, they were exposed to 200 proteins in a single shot. In contrast, the measles vaccine only contains 10.
During the meeting, Kulldorff repeated claims he made in 2024 that he was fired from Harvard because he refused to get the Covid vaccine; he and Malone have also each served as paid expert witnesses in two separate suits against Merck over the safety of the company's HPV vaccine and its mumps vaccine, respectively. Kulldorff did not reply to a request for comment.
The American Academy of Pediatrics (AAP) did not send representatives to last week's ACIP meeting, as it typically does. According to Academy president Susan Kressly, this was because the AAP believes the vaccine recommendation process lost credibility when its original membership was gutted by Kennedy.
"We won't lend our name or our expertise to a system that is being politicized at the expense of children's health," Kressly said in a video posted online before the meeting was set to begin. The AAP did not reply to a request for comment about the video.
The most recent child immunization schedule that the AAP endorses, from November 2024, is posted on the AAP website. A newer one, posted on the CDC site, has already changed recommendations. It no longer lists as "routine" Covid vaccines for children under 18 who are not immunocompromised but instead lists them under vaccines recommended for "shared clinical decision-making," informed by "personal preference and circumstances." The change should not affect insurance coverage.
Blue Cross VT CEO Says Some Progress Made On Health Care Affordability - USA TODAY
Your browser is not supportedusatoday.Com
usatoday.Com wants to ensure the best experience for all of our readers, so we built our site to take advantage of the latest technology, making it faster and easier to use.
Unfortunately, your browser is not supported. Please download one of these browsers for the best experience on usatoday.Com
Herself Health And Blue Cross Blue Shield Reimagine Patient Care
Paywall-free, every day.MinnPost's reporting is always free, but it isn't free to produce. We rely on donations from our readers to fund our independent journalism. Will you join over 4,800 members and make a gift to support our local news coverage today?
Sunday ReviewCatch up on our biggest stories from the past week. Delivered to your inbox Sunday mornings.
Most of us seek care when illness can no longer be ignored, with our providers billed by insurance companies.
A contract between Blue Cross Blue Shield of Minnesota and provider Herself Health, however, focuses on a new way of compensating medical providers – one that focuses on longer visits, preventative care and the health of the patient as a whole. (Blue Cross Blue Shield of Minnesota is a sponsor of the Race and Health Equity beat, but has no editorial say in MinnPost reporting).
"In a fee-for-service world, you go to the doctor's office. You have an appointment. You get seen by the provider and then after the visit they submit a claim and they get paid per visit. What ends up happening is the incentive there is for volume. So the more visits they do, the more that they get paid. So what you have then is a situation – especially in primary care – where the reimbursement rates are quite a bit lower," explained Kristen Helton, Ph.D., chief executive officer of Herself Health. "They're higher for specialists and those who do procedure(s) and can tack on other fees associated with the visit. Primary care practices end up having provider(s) see 35 (or) 40 patients in a day. It's churn and burn and primary care providers (get) burned out because (of) the volume."
Starting retroactively this January, the arrangement Blue Cross and Blue Shield of Minnesota has with Herself Health is a value-based agreement, where providers still are compensated for individual visits, but receive bonuses based on patient health outcomes.
"The agreement really moves away from a traditional fee for service model," said Monica Engel, senior vice president and vice president of government markets at Blue Cross and Blue Shield of Minnesota. "What value-based care really is designed to do is establish some specific quality measures to track and ensure improved health outcomes. Specifically with Herself Health, there are a variety of conditions that commonly affect older women, such as osteoporosis, Alzheimer's, (and) autoimmune diseases."
Herself Health entered into network with Blue Cross and Blue Shield in Jan 2023. But the partnership between the two, said Engel, began at an event from the Women Business Leaders Organization.
"Kristen and I were at (this) event together (and) she shared with me the great work that was happening with Herself Health opening clinics here in Minnesota. I was very intrigued by this opportunity that we had to do business with Herself Health. I am a huge advocate for women's health and, as I think about the senior population, you know, this is really an area of opportunity for us to think about how women, as they transition through various phases of their life, are able to get quality healthcare in a different way. (I) had an opportunity to introduce (Helton) to our network team and the rest is history," said Engel.
The beginnings of Herself Health, said Helton, came out of research into older adults in 2021.
"In some of these focus groups discussing their needs and wants, there was a really clear signal, especially from women, that they wanted a better health care experience and there were a lot of common themes about not feeling seen, not feeling heard (and) being dismissed," said Helton. "Women's health always defaults to fertility (and) maternity, which is such a small portion of our lives. It's a very important (part), but when you think about the life journey of a woman, it's finite and not everyone makes those choices. Women's health is something that is bigger and broader (than just reproductive health)."
Herself HealthHerself Health has four clinics in Minnesota, with a new clinic set to open in November in Eagan. The clinics offer care to women aged 65 and older, a group that often feels invisible, says Becca Kummer, clinical manager at Herself Health's clinic in Highland Park.
Kummer described the patient population at Herself Health as coming to the clinic having felt unseen or unheard by previous providers, with any discomfort written off as "just a sign of aging" or otherwise dismissed. At Herself Health, Kummer said, patients are made partners in their health care journey. Initial appointments are lengthy, starting with a meeting with the clinic's patient service liaison to discuss insurance followed by a visit with a provider, and a 10 minute discharge with a medical assistant.
Kummer summarizes Herself's approach as one where "we see you more often to keep you well," with routine laboratory work and checking in with the patient concerning their mental health. The clinic also hosts various wellness events in their facility or outside their facility to allow patients to take charge of their health and to meet with each other to combat loneliness, which has adverse effects on mental wellbeing.
Specialized care for this patient population, according to lead nurse practitioner Tara McCollough, can also look like de-prescribing medication that may have been helpful previously, but that may not work or have adverse effects for an older person. For example, McCollough said, overmedication of blood pressure medication may cause falls, which can be physically damaging for older adults.
The cost of careBy including bonus payments to providers for meeting certain patient health care outcomes and metrics in addition to billing insurance for individual visits, Herself aims to lower health care costs through preventative care.
"If all of our patients have the expected screenings, and (we meet various) healthcare measures of quality, we get bonus payments. It's a way to incentivize providers to take a bit more time (and) to do more preventative medicine because we know that doing those things early (and) detecting things early lead(s) to better outcomes and lower costs," said Helton. "We're incentivized to keep people out of high cost places like emergency rooms and inpatient (care)."
"We want to make sure that we can get our members on the front end of preventive care," said Engel of Blue Cross Blue Shield members. "One of the pieces that I really appreciate (about) Herself Health (is that) you get that one stop shop (to) help you navigate your care as you move through that journey."
Helton also pointed out that women tend to be the "household CEOs of health care," responsible not just for taking care of their own health, but of their family members' health as well.
"This is a group who for so long have been caretakers," said Kummer. "We need to care for them."
Editor's Note: A previous version of this article stated that Herself Health was not able to treat dermatological and gastrointestinal concerns or perform physical therapy in-house. Herself Health has indicated that it is able to perform these procedures in house.
You need us and we need you.
MinnPost's local news coverage relies on the support of readers like you. And you rely on us to bring you trusted, independent journalism. Support this work with a monthly donation today.
Comments
Post a Comment