End of the Pandemic Emergency, RSV vaccines , new draft breast cancer recommendations, and making childbirth safer
May 12, 2023
Happy Friday!
Today, I’ll discuss the implications of the end of the Pandemic Emergency for employers, approval of an RSV vaccine for those sixty and over, and specific actions employers can take to make childbirth safer in the US.
1. The Pandemic Emergency ended yesterday. What should employers do?
The World Health Organization stated that COVID-19 no longer remained a public health emergency of international concern on May 5, and the US Pandemic Emergency ended yesterday. This doesn’t mean that COVID-19 is no longer a danger. Rather, COVID-19 is now a permanent part of the ecosystem, and we need to think about the coronavirus in the context of all other health risks.
Here’s a review of what this means for employers.
● COVID-19 Vaccinations
COVID-19 vaccinations must still be covered without charge by employer-sponsored health insurance, as these are recommended by the CDC’s Advisory Committee on Immunization Practice. Vaccine mandates helped increase vaccination rates in 2021 when they were first implemented, but most employers outside of health care have already discontinued the vaccine mandate. That’s because vaccination a year or more ago provides little protection against bringing COVID-19 to the workplace now.
The federal government is still paying for vaccines (and employer-sponsored health insurance pays for the administration fee.) However, employer plans will pay for the vaccine itself starting this fall. The Centers for Disease Control and Prevention recommends that everyone who was vaccinated in the past get one booster shot with the bivalent vaccine, and those who are over 65 or those with immune compromise who were last vaccinated more than two months ago should get a booster this spring.
● Over the Counter COVID-19 Tests
Employers are no longer required to cover rapid antigen at home tests, and most employers will cease coverage of these tests. This decision is consistent with overall health plan design; health plans rarely reimburse for over-the-counter supplies. Some employees might still be eligible to get four tests per address from the federal government until the end of this month, and some can find tests at libraries and other local government buildings. Many test kits remain fresh after their printed expiration date. Hopefully, the price of tests will decrease rapidly when consumers must pay for them directly. Rapid antigen tests currently cost under $1.40 each in the United Kingdom.
● Laboratory COVID-19 tests
Employers will no longer be required to cover out-of-plan PCR tests and will no longer be required to waive member cost-sharing for COVID-19 tests. Most employers will now cover these tests the same way they cover diagnostic tests for other infectious or non-infectious diseases, so these tests will probably require a physician’s prescription. Individuals can be treated for COVID-19 based on rapid antigen (home) tests, so this should not prevent appropriate care for those who have infections.
● COVID-19 medications
Employers will no longer be required to waive cost sharing on COVID-19 medications such as Paxlovid. The federal government continues to supply the medication now, so employer-sponsored health insurance is only responsible for administration fees, although the employer plans will also have to start paying for the drug itself when the federal supply runs out.
● Telemedicine
Many of the federal rules that enabled more virtual care during the pandemic have been extended. Providers will continue to be able to prescribe opioid use disorder medications without an in-person appointment. The ability to prescribe other controlled substances to new patients via telemedicine is extended temporarily until November 11, 2023, and to prescribe controlled substances to existing patients is extended until November 11, 2024. Pandemic exemptions that allowed providers to write prescriptions for patients in states where they are licensed will not be continued, though, so some providers might limit the geography for virtual care they provide. Some employers will retain lower cost sharing for virtual care, and most will continue to provide coverage for virtual care.
● Workplace protection
Employers made substantial efforts to decrease the risk of workplace transmission and will hopefully continue these efforts. For instance, improving indoor air exchange and filtration lowers risk of influenza, COVID, and other respiratory diseases, and improves productivity. Employers can also continue to make it easy for employees to wash their hands and provide sick time so employees don’t feel obligated to come into work when they feel sick. Many workers continue to work remotely for at least a part of the week, which decreases employee density and diminishes the cost and risks associated with commuting.
● Mental health
The prevalence of major symptoms of anxiety or depression has tripled since 2019, and employers can continue to offer generous coverage of both in-person and virtual mental health care. Virtual care has improved mental health access, and mental health visits make up the majority of virtual visits across the country. Many employers continue to offer lower cost sharing for members using virtual care.
Here's a link to a post by my WTW colleague Erin Terkoski Young, MSW on how employers can assess their mental health offering.
2. RSV vaccines are coming!
Respiratory syncytial virus (RSV) causes 58,000 to 80,000 hospitalizations of children under 5 each fall. European researchers found that 1.8% of all healthy full-term infants were hospitalized with RSV before their first birthday. This year’s RSV epidemic was especially terrible; many cities had no available pediatric inpatient beds. RSV also causes about 60,000 to 160,000 hospitalizations and 6000-10,000 deaths in adults annually - mostly in the elderly.
The Food and Drug Administration (FDA) just approved Arexvy (GSK) the first respiratory syncytial (RSV) vaccine for adults ages 60 and over; this will be available later this year, and the price range is expected to be between $60 and $185. The Advisory Committee on Immunization Practice (ACIP) is expected to make recommendations on this vaccine in June.
Most children hospitalized with RSV are under six months old, and there is no vaccine available for children at this time. A study published last month in the New England Journal of Medicine with over 3600 pregnant women vaccinated, showed an 82% effectiveness rate at preventing severe infection in their newborns at 90 days, and a 70% effectiveness rate at 180 days. There is one monoclonal antibody currently available to prevent severe RSV infections Synagis (palivizumab). However, it costs $5,000 to $10,000 per infant, and is recommended only for those at exceptionally high risk such as premature infants. A second monoclonal antibody (Nirsevimab) might be available before this fall’s RSV season. A second RSV vaccine for older adults and pregnant (Abrysvo, Pfizer) is also under review but has not yet been approved.
Implications for employers:
- Employers will likely need to add the adult RSV vaccine to their formularies with no cost sharing after the expected ACIP recommendation next month. Financial implications are likely to be small, as this is not recommended under age 60 and it will prevent some hospitalizations.
- The second monoclonal antibody for infants was shown to be effective at preventing infections even in low-risk infants, so could be recommended for a larger portion of newborns than Synagis.
- The FDA is expected to review the vaccine for pregnant women this summer, and hopefully it will be available for the 2023-24 RSV season.
- This could be the beginning of an age where children’s hospitals will not be filled with the painful wheezing of desperately ill infants in the fall and winter.
3. USPSTF issues draft recommendation to begin mammography at age 40
The US Preventive Services Task Force (USPSTF) issued a draft recommendation Wednesday to lower the age of initial mammography to age 40. This draft recommendation will be open for comments for a few months and will likely be finalized in the fall. The current USPSTF recommendation is for mammography every other year, although the American Cancer Society recommends annual mammograms from ages 45-54.
The USPSTF points to changes since their last review of this recommendation in 2016, including an increased rate of breast cancer detection in women under 50 and improved mammograms that should yield fewer false positives. They also note that Black women have much higher mortality from breast cancer and lowering the age of first screening could diminish this disparity.
Implications for employers:
- These recommendations are just “draft now”
- Most employers cover screening mammography without cost sharing at age 40 already anyway, as the Affordable Care Act specified that plans must follow the USPSTF guidelines on breast cancer screening from before 2009, when the recommended age of first mammogram was lower. Further, most employer plans already cover mammograms without cost sharing every year. Restricting to every other year would mean that almost all women would get mammograms less frequently than recommended.
- If upheld, the recent Braidwood Management vs. Becerra decision on the ACA’s preventive care mandate would ‘freeze’ requirements to waive cost sharing limiting enforcement to USPSTF recommendations in place before March 23, 2010. This would make no difference in this instance, but this illustrates the challenge of freezing plan design on preventive guidelines that might become obsolete with changing knowledge and practice.
4. Employers can make childbirth safer in America.
Gates Foundation, 2021, LINK
The dangers of childbirth are substantially higher in the US than in other wealthy countries, and maternal mortality is rising in this country. Sixty thousand or more women face severe and potentially life-threatening maternal morbidity each year, and almost a third of births are performed via Cesarean Section – a rate double that recommended by the World Health Organization.
Here’s a link to an article I published in Harvard Business Review late last month; I wanted to review a few of these recommendations.
Benefit design: Employers can review their benefit design to be sure they are offering leave, clinical support, and mental health services to support women and their families. Employers pay for about half of all deliveries, and shouldn’t underestimate how their influence on health plans can promote improved quality of care.
Member education: Employers can require their health plans to provide information about quality of care, access to midwives and doulas, and likelihood of Cesarean section
Plan reporting: Employers can require their health plans to provide them with meaningful reporting
Provider payment: Plans can rethink how they pay for hospitalizations; currently, hospitals have higher margins from Cesarean section deliveries.
Centers of Excellence: Many women don’t have much local choice for maternity providers, but employers can require that plans don’t give “preferred” or “excellence” status on facilities that are only mediocre.
Employer efforts have helped drive improvement in maternity care before. A concerted effort to decrease deliveries before 39 weeks that were not medically indicated has dramatically decreased early elective deliveries. Employers should use their influence to improve the safety of childbirth in the US.
Hope all have a good weekend when it comes!
Jeff