Adult Immunization, Patient-Centered Medical Care, and the Primary Physician John H. O Neill, Jr., D.O., FACP Bayview Internal Medicine, Inc., Middletown, Delaware Chair, Immunization Technical Advisory Committee, ACP NJ Adult Immunization Summit November 4, 2015, Princeton 1
Disclosure Dr. John O Neill has received a stipend from ACP to assist in the development of educational programs and tools to promote adult immunization, and otherwise has NO financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services, consumed by, or used on, patients. 2
Objectives Briefly Review the Immunizationsthat are indicated for adult patients in 2015 Explore team-based strategies for providing efficient and automated, patient-centered adult immunizations in the Primary Medical Practice Touch on some important Cost considerations 3
The Big Five for Adults Influenza Td/Tdap PCV13 (conjugated pneumococcal) PPSV23 (pneumococcal polysaccharide) Zoster (VZV) 5
The Other Seven for Adults: individual circumstances HPV2/HPV4/HPV9 Meningococcal Hepatitis B Hepatitis A MMR Varicella Hib 6
NHIS 2013, non-flu immunization Immunization Age range % Received Source: cdc.gov/mmwr/preview 2/6/15 Pneumococcal 19-64 >65 Tetanus 19-64 >65 Tetanus/Pertussis 19-64 >65 Hepatitis B 19-49 With hx DM 21.2 59.7 63 56 18.4 (+2.9%) 11.9 32.6 26.3 Zoster >60 24.2 (+4.1%) HPV (female) 19-26 female 19-21 male 36.9 7.7 (+5.3%) 7
US Adult Immunization Rates are Unacceptably Low! Source: www.cdc.gov/flu/fluvaxview 8
ACIP 2015: Influenza Annual influenza vaccination is recommended for all persons > 6 months of age If hives-only egg allergy, ok to give IIV (age-approp.) Recombinant influenza vaccine (RIV) can be given to persons > 18 if hxegg allergy of any severity LAIV: ages 2-49, an option for healthy, non-pregnant Intradermal IIV is an option for ages 18-64 Pt s > 65 can receive standard or high dose IIV http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf 9
Some Types of Flu Vaccines: 14-15 CPT code MCR Q code Vax Type Brand Name 90654 (18-64 y/o) IIV3 Fluzone intraderm 90656 (preservative free) IIV3 (pf) Fluzone, Fluvirin, Fluarix, Afluria 90658* Q2035 IIV3 Afluria 90658* Q2037 IIV3 Fluvirin 90658* Q2038 IIV3 Fluzone 90661 cell culture, no egg cciiv3 Flucelvax 90662 (preservative free) IIV3hd Fluzone-HiDose 90672 (2-49 y/o) LAIV4 FluMist 90673* (18 y/o and up) Q2033 RIV3 FluBlok 90686 (quadriv, pres free) IIV4 (pf) FluZone 90688 (quadriv) IIV4 FluLaval, Fluzone 10
Avian.gif 11
ACIP 2015: Td/Tdap Administer 1 dose of Tdapto pregnant patients in 3 rd trimester, with eachpregnancy Persons >10 y/o, give Tdapif not given previously or if unsure of hx, then Td every 10 yrthereafter Adults with no known hxof primary series should receive a 3-shot series, one of them being Tdap, the other 2: Td, at months 0, 1 and 6 For wound, post-exposure prophylaxis, can use Tdapif not given previous and last Td > 9 yrs 12
ACIP 2015: Pneumococcal PCV13, once for all persons 65 and up (if not before) PPSV23, give one year after PCV13 If PPSV23 already given, PCV13 should be given not sooner than 12 months after PPSV23 For < 65 y/o: PCV13 once, then PPSV23 (1 yrlater, and boost in 5 yr), for nephrotic, immunosuppressed pt s, and those w/ cochlear implant or CSF leak, and functional/anatomic asplenia For < 65 y/o: PPSV23 once for above, also smokers, long term care residents and for chronic heart, lung, liver, kidney disease/diabetes; can boost in 5 yrfor higher risk patients 13
ACIP 2015: Zoster Once after age 60, SQ injection, without regard for previous Zoster (> 1yr) or Varicella Hx Live attenuated virus, avoid in pregnant or immunosuppressed Store in freezer (-58 to +5 degrees F, -50 to -15 C) About 50% effective in preventing Zoster Reduced severity of Zoster (pain) by 66% in those who developed Zoster subsequent to having received the vaccine 15
Vaccines, Cost and Reimbursement http://www.cdc.gov/vaccines/programs/vfc/awardees/vaccinemanagement/price-list/index.html vaccine cpt Icd10 Approx. Cost* (*VCF) Est. Private Sector reimb. Mcr (DE ) reimb. Influenza (pres. free) 90656 Z23 12.30-15.00 14-20 13.88 Influenza (IIV3) 90658 Z23 10.55-15.00 12-16 12.44 Influenza (hi dose ag, > 65 y/o) 90662 Z23 28-30 32-34 36.31 Influenza quadrivalent (pf) 90686 Z23 17.97 18.15 PPSV23 90732 Z23 72.38 69-78 82.51 Tdap 90715 Z23 37-42 40-47 Herpes Zoster 90736 Z23 187.89 190-197 PCV13 97670 Z23 152 148-151 173.15 Hepatitis B 90746 Z23 52-61 56-59 59.70 Meningococcal (conj.) 90734 Z23 112.93 120-123 HPV (9 valent) 90651 Z23 163.09 16
Vaccine Administration Vaccine MCR (HCPCS) MCR Pmt (DE ) PAR Non-MCR CPT Private Sector reimburse Influenza G0008 25.81 90471 10-12.80 Pneumococcal G0009 25.81 90471 10-12.80 Hepatitis B G0010 25.81 90471 10-12.80 Second Vax Admin per day Administer Vax <age 18, with counselling (use icd9 V06.6 if flu vax and PPSV23 given same day) 12.85 90472 90460, 90461 10-12.80 17
Team-based Immunization Pre-visit planning: (receptionist and MA/RN) identify scheduled patients Charts are pulled to identify deficits and opportunities for vaccination Standing Orders: Immunization Action Coalition http://www.immunize.org/standing-orders/ Patient receives needed vaccine after rooming and prior to physician seeing them Post-visit intervention: PM system reporting identifies patients who have not been in for a defined interval, charts pulled, opportunities for vaccination id d, patients contacted 18
Vaccine Storage 19
Other cost considerations: Digital Thermometers: http://www.vfcdataloggers.com/ Vaccine refrigerators: consider thermo.com, fischersci.com, sunfrost.com, labresprod.com Storage and handling of vaccines: best practices http://www.cdc.gov/vaccines/recs/storage/toolkit/storagehandling-toolkit.pdf Vaccine DiscountSuppliers: ***buying vaccines for less $$$(eg. Vaxserve.com, AHP: atlantichealthpartners.com, and NVDA: nationaldiscountvaccinealliance.com) **see also AAP web site 20
Thank you! drjho7@verizon.net 21