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United States Government Accountability Office: 
GAO: 

Report to Congressional Committees: 

December 2011: 

Medicare: 

Many Factors, Including Administrative Challenges, Affect Access to 
Part D Vaccinations: 

GAO-12-61: 

GAO Highlights: 

Highlights of GAO-12-61, a report to congressional committees. 

Why GAO Did This Study: 

Vaccinations can prevent diseases and improve the quality of life for 
Medicare beneficiaries. Vaccinations for flu and pneumonia are covered 
by Medicare’s Part B physician and outpatient service benefit. Since 
2006, Medicare’s Part D prescription drug benefit covers other 
routinely recommended vaccinations, such as the shingles vaccination. 
Part D typically contracts with pharmacies, but not physicians, for 
covered vaccinations. The Patient Protection and Affordable Care Act 
required GAO to study Medicare beneficiary access to routinely 
recommended vaccinations covered under Part D. GAO examined (1) the 
extent to which beneficiaries have received Part D-covered 
vaccinations, (2) factors affecting beneficiary access to 
vaccinations, and (3) any findings and recommendations of government 
agencies and other stakeholders to increase access to Part D-covered 
vaccinations. To do this, GAO (1) analyzed Centers for Disease Control 
and Prevention (CDC) national health survey data and Medicare data; 
(2) surveyed physicians, pharmacies, and state beneficiary assistance 
programs nationwide; and (3) convened a facilitated discussion with 
stakeholder groups. 

What GAO Found: 

Many of the almost 22 million Medicare beneficiaries age 65 and older 
who were enrolled in Medicare Part D in 2009 did not receive the 
routinely recommended vaccinations covered by Part D. CDC national 
survey data for 2009 show that 11 percent of Medicare beneficiaries 
age 65 and older had received a shingles vaccination and 53 percent 
had received a Td (tetanus and diphtheria) vaccination—-the routinely 
recommended vaccinations covered under Part D. Medicare data for 2007 
through 2009 show that relatively few Part D beneficiaries received 
these vaccinations under Part D-—5 percent for shingles and less than 
1 percent for Td or Tdap (which includes protection against 
pertussis). These data suggest that beneficiaries either received 
vaccinations prior to enrolling in Medicare or, once enrolled, used 
other health coverage or paid out of pocket for these vaccinations. 

A multitude of factors affect beneficiaries’ access to routinely 
recommended Part D-covered vaccinations, particularly the low 
percentage of physicians and pharmacies that stock the relatively new 
shingles vaccine (see figure). Most physicians do not stock the 
shingles vaccine due to factors such as the cost of purchasing a 
supply and Part D billing challenges. More than half of physicians 
refer beneficiaries to pharmacies to purchase the vaccine—which may 
require beneficiaries to transport the vaccine back to the physician 
to be administered. Physicians recommend shingles vaccinations less 
often than other vaccinations, and even when they recommend them, 
beneficiaries often decline them. At the same time, due in part to a 
limited supply of the shingles vaccine, only about one-third of 
pharmacies nationwide stock it. Beneficiaries’ cost sharing—which 
averaged $57 for a shingles vaccination in 2009—and challenges with 
obtaining reimbursement from Part D plans were other reported 
deterrents to beneficiaries’ obtaining Part D vaccinations. 

Figure: Physicians’ and Pharmacies’ Stocking Practices for the 
Shingles Vaccine, 2010: 

[Refer to PDF for image: 2 pie-charts] 

Physicians: 
Stock the vaccine: 31%; 
Do not stock the vaccine: 69%. 

Pharmacies: 
Stock the vaccine: 35%; 
Do not stock the vaccine, refer beneficiaries to a physician for 
vaccination: 40%; 
Do not stock the vaccine: 26%. 

Source: GAO. 

Note: Percentages may not total to 100 percent due to rounding. 

[End of figure] 

Many stakeholders-—government agencies, advisory bodies, and 
professional organizations-—have raised concerns about the 
administrative challenges associated with Part D and have recommended 
actions to improve access to Part D vaccinations. The Centers for 
Medicare & Medicaid Services has issued guidance on a number of 
approaches to help address administrative challenges, but stakeholders 
report that additional steps are needed, including broader use of web-
based systems, that could provide real-time access to allow physicians 
to verify beneficiary coverage and bill Part D plans. 

What GAO Recommends: 

GAO recommends that CMS explore options and take appropriate steps to 
address administrative challenges, such as physicians’ difficulty 
verifying beneficiary coverage and billing for Part D-covered 
vaccinations. The Department of Health and Human Services concurred 
with GAO’s recommendation. 

View [hyperlink, http://www.gao.gov/products/GAO-12-61]. For more 
information, contact Katherine Iritani at (202) 512-7114 or 
iritanik@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

About One-Tenth of Medicare Beneficiaries Have Received Shingles 
Vaccinations, about Half Have Received Td Vaccinations, and Relatively 
Few Received Them under Part D: 

A Multitude of Factors Affect Beneficiaries' Access to Part D-Covered 
Vaccinations, Particularly for Shingles: 

Stakeholders' Recommendations to Improve Access to Part D Vaccinations 
Include Facilitating Payment to Physicians and Increasing Pharmacists' 
Authority to Administer Vaccinations: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments: 

Appendix I: Scope and Methodology: 

Appendix II: Shingles Risk, Prevalence, and Vaccine Supply: 

Appendix III: Centers for Disease Control and Prevention National 
Survey and Medicare Part D Data for Selected Demographics: 

Appendix IV: Selected Results of the GAO 2010 Physician Survey: 

Appendix V: Selected Results of the GAO 2010 Pharmacy Survey: 

Appendix VI: State Health Insurance Assistance Program Survey Results: 

Appendix VII: Beneficiaries' Part D Cost Sharing for Shingles and 
Td/Tdap Vaccinations: 

Appendix VIII: Comments from the Department of Health and Human 
Services: 

Appendix IX: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Medicare Enrollment, Age 65 and Older, 2009: 

Table 2: Medicare Coverage of ACIP's Routinely Recommended Preventive 
Vaccinations for Adults Age 65 and Older, February 2011: 

Table 3: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving Shingles Vaccination or Receiving Td Vaccination in Previous 
10 Years, 2007 through 2009: 

Table 4: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving Shingles Vaccination or Receiving Td Vaccination in Previous 
10 Years, by Insurance Coverage, 2009: 

Table 5: Vaccinations Reimbursed by Part D for Medicare Beneficiaries, 
by Part D Plan Type and LIS Status, 2007 through 2009: 

Table 6: Barriers Cited by Physicians Who Do Not Stock the Shingles 
Vaccine: 

Table 7: Barriers Cited by Pharmacies That Do Not Stock the Shingles 
Vaccine: 

Table 8: Barriers Cited by Pharmacies That Do Not Stock the Td/Tdap 
Vaccines: 

Table 9: Number of SHIPs Reporting Beneficiary Difficulties Accessing 
Shingles, Td/Tdap, and Pneumococcal Vaccinations: 

Table 10: Cost Sharing and Retail Prices for the Shingles and Tetanus 
Vaccines, 2009: 

Table 11: IOM-Facilitated Discussion Participants: 

Table 12: Doses of Shingles Vaccine Produced, 2006 through 2011: 

Table 13: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving a Shingles Vaccination or Receiving a Td Vaccination in 
Previous 10 Years, 2009: 

Table 14: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving Shingles Vaccination or Receiving Td Vaccination in the 
Previous 10 Years, 2007 through 2009: 

Table 15: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving Shingles Vaccination or Receiving Td Vaccination in the 
Previous 10 Years, by Insurance Coverage, 2009: 

Table 16: Vaccinations Reimbursed by Part D for Individuals Age 65 and 
Older by Demographic Group, 2007 through 2009: 

Table 17: Frequency of Physician Vaccination Recommendations: 

Table 18: Frequency of Beneficiary Declinations after Physicians Have 
Recommended the Vaccinations: 

Table 19: Reasons for Beneficiary Declinations: 

Table 20: Physician Stocking Practices: 

Table 21: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by All Physicians: 

Table 22: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by Physicians Who Stock the Vaccine: 

Table 23: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by Physicians Who Do Not Stock the Vaccine: 

Table 24: Barriers to Stocking, Administering, or Recommending Td/Tdap 
Vaccines, Reported by All Physicians: 

Table 25: Barriers to Stocking, Administering, or Recommending Td/Tdap 
Vaccines, Reported by Physicians Who Stock the Vaccines: 

Table 26: Barriers to Stocking, Administering, or Recommending Td/Tdap 
Vaccines, Reported by Physicians Who Do Not Stock the Vaccines: 

Table 27: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by All Physicians: 

Table 28: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by Physicians Who Stock the Vaccine: 

Table 29: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by Physicians Who Do Not Stock the 
Vaccine: 

Table 30: Physicians' Awareness and Use of Web-Assisted Billing 
Systems: 

Table 31: Physicians' Recommendations to Make It Easier for Physicians 
to Stock and Administer All Routinely Recommended Vaccines: 

Table 32: Pharmacy Stocking Practices: 

Table 33: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by All Pharmacies: 

Table 34: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by Pharmacies That Stock the Vaccine: 

Table 35: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by Pharmacies That Do Not Stock the Vaccine: 

Table 36: Barriers to Stocking, Administering, or Recommending the Td/ 
Tdap Vaccines, Reported by All Pharmacies: 

Table 37: Barriers to Stocking, Administering, or Recommending the Td/ 
Tdap Vaccines, Reported by Pharmacies That Stock the Vaccines: 

Table 38: Barriers to Stocking, Administering, or Recommending the Td/ 
Tdap Vaccines, Reported by Pharmacies That Do Not Stock the Vaccines: 

Table 39: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by All Pharmacies: 

Table 40: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by Pharmacies That Stock the Vaccine: 

Table 41: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by Pharmacies That Do Not Stock the 
Vaccine: 

Table 42: Pharmacies' Recommendations to Make It Easier for Pharmacies 
to Stock and Administer All Routinely Recommended Vaccines: 

Table 43: Number of SHIPs Helping Beneficiaries Understand Medicare 
Vaccination Coverage: 

Table 44: Number of SHIPs Reporting Beneficiary Difficulties Accessing 
Shingles Vaccinations: 

Table 45: Number of SHIPs Reporting Beneficiary Difficulties Accessing 
Td/Tdap Vaccinations: 

Table 46: Number of SHIPs Reporting Beneficiary Difficulties Accessing 
Pneumococcal Vaccinations: 

Table 47: SHIP Recommendations to Improve Beneficiaries' Access to 
Routinely Recommended Vaccinations: 

Table 48: 2009 Cost-Sharing Amounts for Shingles Vaccinations by Phase 
for Beneficiaries Age 65 and Older with Part D Coverage (Non-LIS): 

Table 49: 2009 Cost-Sharing Amounts for Td/Tdap Vaccinations by Phase 
for Beneficiaries Age 65 and Older with Part D Coverage (Non-LIS): 

Table 50: Average Cost-Sharing Amounts for Shingles and Td/Tdap 
Vaccinations for Non-LIS Part D Beneficiaries Age 65 and Older, 2007 
through 2009: 

Figures: 

Figure 1: Physicians Stocking the Shingles, Td/Tdap, and Pneumococcal 
Vaccines: 

Figure 2: Physicians Stocking the Shingles, Td/Tdap, and Pneumococcal 
Vaccines, by Practice Size: 

Figure 3: Referral Practices of Physicians Who Do Not Stock the 
Shingles Vaccine: 

Figure 4: Physician Recommendations for the Shingles, Td/Tdap, and 
Pneumococcal Vaccines: 

Figure 5: Beneficiary Declinations of Shingles, Td/Tdap, and 
Pneumococcal Vaccinations after Physicians Have Recommended Them: 

Figure 6: Pharmacies Stocking the Shingles, Td/Tdap, and Pneumococcal 
Vaccines: 

Abbreviations: 

ACIP: Advisory Committee on Immunization Practices: 

CBO: Congressional Budget Office: 

CDC: Centers for Disease Control and Prevention: 

CMS: Centers for Medicare & Medicaid Services: 

HHS: Department of Health and Human Services: 

IOM: Institute of Medicine: 

LIS: low-income subsidy: 

MedPAC: Medicare Payment Advisory Commission: 

MMA: Medicare Prescription Drug, Improvement, and Modernization Act of 
2003: 

NHIS: National Health Interview Survey: 

PPACA: Patient Protection and Affordable Care Act: 

SHIP: State Health Insurance Assistance Program: 

SSA: Social Security Act: 

Td: tetanus and diphtheria vaccine: 

Tdap: tetanus, diphtheria, and acellular pertussis vaccine: 

USPSTF: U.S. Preventive Services Task Force: 

United States Government Accountability Office: 
Washington, DC 20548: 

December 15, 2011: 

The Honorable Max Baucus: 
Chairman: 
The Honorable Orrin G. Hatch: 
Ranking Member: 
Committee on Finance: 
United States Senate: 

The Honorable Fred Upton: 
Chairman: 
The Honorable Henry A. Waxman: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable David Camp: 
Chairman: 
The Honorable Sander M. Levin: 
Ranking Member: 
Committee on Ways and Means: 
House of Representatives: 

Vaccinations have the potential to prevent diseases and improve the 
quality of life for individuals enrolled in Medicare--the federal 
health insurance program that covered nearly 38 million beneficiaries 
age 65 and older in 2009.[Footnote 1] Upon its establishment in 1965, 
Medicare generally covered treatment services if a beneficiary became 
ill or injured. Over time, Congress broadened Part B--which pays for 
physician and other outpatient medical services--to cover certain 
preventive services, including vaccinations to protect against 
pneumonia and influenza.[Footnote 2] When the Part D outpatient 
prescription drug benefit began in January 2006, it expanded Medicare 
coverage to encompass all routinely recommended vaccinations that were 
not specifically covered under Part B.[Footnote 3] As of August 2011, 
the primary routinely recommended vaccinations covered under Part D 
are the onetime vaccination to prevent shingles--a viral infection 
that produces a painful, blistering rash and affects nearly 1 million 
individuals each year[Footnote 4]--and vaccinations to help prevent 
tetanus and diphtheria (Td vaccine) or tetanus, diphtheria, and 
pertussis (Tdap vaccine).[Footnote 5] These vaccines can greatly 
reduce the burden of preventable disease in older Americans. For 
example, the shingles vaccine--first approved in 2006--has been shown 
to reduce the overall incidence of shingles in older adults by about 
half and to reduce the incidence of postherpetic neuralgia by about 
two-thirds.[Footnote 6] Due in part to the importance of routinely 
recommended vaccinations covered under Part D as preventive services, 
long-standing interest exists in ensuring that beneficiaries are able 
to access them. In addition, newly developed vaccines that become 
recommended for routine administration to Medicare beneficiaries would 
also be covered under Part D. 

A number of stakeholders are involved in ensuring that Medicare 
beneficiaries have access to routinely recommended vaccinations, 
including those covered under Part D. The Department of Health and 
Human Services' (HHS) Centers for Disease Control and Prevention (CDC) 
and its Advisory Committee on Immunization Practices (ACIP) make 
recommendations for adult immunizations. HHS's Centers for Medicare & 
Medicaid Services (CMS) administers Medicare, including Part D. CMS 
contracts with private Part D plan sponsors that offer prescription 
drug plans to Medicare beneficiaries. Although the plans may differ in 
the drugs they cover and in the pharmacies they use, all Part D plans 
must cover all licensed vaccines not covered under Part B.[Footnote 7] 
Other stakeholders include physicians, who traditionally administer 
vaccinations, and pharmacists, who dispense vaccines and can 
administer them in most states. 

The Patient Protection and Affordable Care Act (PPACA) required us to 
study the ability of Medicare beneficiaries age 65 and older to access 
routinely recommended vaccinations covered under Medicare Part D. 
[Footnote 8] This report discusses (1) the extent to which Medicare 
beneficiaries have received the routinely recommended vaccinations 
covered under Part D; (2) factors that could affect Medicare 
beneficiaries' access to the routinely recommended vaccinations 
covered under Part D; and (3) any findings and recommendations from 
government agencies, advisory bodies, professional organizations, and 
other stakeholders to increase access to routinely recommended 
vaccinations under Part D. 

To determine the extent to which Medicare beneficiaries age 65 and 
older[Footnote 9] have received the routinely recommended vaccinations 
covered under Part D, we (1) obtained information on recommended 
vaccinations for adult Medicare beneficiaries by reviewing 
recommendations of and interviewing officials from CMS, CDC, ACIP, and 
the National Vaccine Advisory Committee;[Footnote 10] (2) analyzed 
data from the 2007 National Immunization Survey and the 2008 and 2009 
National Health Interview Surveys (NHIS)[Footnote 11] administered by 
CDC's National Center for Health Statistics on the percentage of 
adults age 65 and older, both with and without Part D coverage, who 
reported ever receiving a shingles vaccination or receiving a Td 
vaccination in the prior 10 years;[Footnote 12] (3) analyzed Part D 
data from 2007 through 2009, focusing on data for shingles and Td/Tdap 
vaccinations;[Footnote 13] and (4) obtained enrollment data on 
Medicare beneficiaries with Part D coverage. To assess the reliability 
of the CDC and Medicare data, we interviewed knowledgeable officials, 
reviewed relevant documentation, and compared our results to published 
data. We determined that these data were sufficiently reliable for the 
purposes of our engagement. 

To identify factors that could affect Medicare beneficiaries' access 
to the routinely recommended vaccinations covered under Part D, we (1) 
reviewed relevant laws, regulations, and guidance on coverage of 
routinely recommended adult vaccinations under Medicare; (2) surveyed 
nationally representative samples of 6,500 primary care physicians--
family and internal medicine physicians--and 1,500 pharmacies to 
obtain information on common provider practices for the shingles and 
Td/Tdap vaccinations covered under Part D and, for comparison, the 
pneumococcal vaccination covered under Part B; (3) surveyed State 
Health Insurance Assistance Programs (SHIP)--state agencies that 
provide counseling and assistance to Medicare beneficiaries--for all 
51 states, including the District of Columbia, to obtain information 
on any beneficiary questions and difficulties related to vaccinations 
covered under Part D;[Footnote 14] (4) analyzed Part D data from 2007 
through 2009, focusing on reimbursement methods and beneficiaries' 
cost sharing for Part D vaccinations; (5) interviewed a judgmental 
selection of nursing home administrators who represent members of the 
American Health Care Association and the American Association of Homes 
and Services for the Aging; and (6) interviewed officials from six 
Part D plan sponsors that cover almost 40 percent of all Part D 
beneficiaries. We also examined information on the extent to which 
Medicare beneficiaries under the age of 65 and those residing in 
nursing homes face unique barriers to Part D vaccinations. 

To examine any findings and recommendations from government agencies, 
advisory bodies, professional organizations, and other stakeholders to 
improve access to routinely recommended vaccinations under Medicare 
Part D, we (1) interviewed relevant stakeholders, including officials 
representing government agencies, advisory bodies, provider 
professional organizations, Part D plan sponsors, and Medicare 
beneficiary advocacy organizations; (2) contracted with the National 
Academy of Sciences to have the Institute of Medicine (IOM) convene a 
group of key stakeholder to discuss vaccinations covered under Part D; 
and (3) conducted a literature review of articles from peer-reviewed 
journals, as well as documents, letters, reports, and other materials 
provided by federal agencies, advisory bodies, and industry 
organizations. In addition, we compared the proposals identified 
through the interviews, discussion, and literature review to responses 
to our provider and SHIP surveys. 

We conducted this performance audit from September 2010 to December 
2011 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. (For more 
information on our scope and methodology, see appendix I.) 

Background: 

Medicare Enrollment and Coverage Options: 

Medicare, the federal health insurance program for Americans age 65 
and older and for certain individuals with disabilities, as well as 
individuals with end-stage renal disease, consists of four parts, 
Parts A through D. Almost all adults age 65 and older are 
automatically enrolled as beneficiaries in Part A, which covers 
inpatient services in hospitals and hospices, related posthospital 
care in skilled nursing facilities, and home health services.[Footnote 
15] Medicare beneficiaries have the option to enroll in Part B, which 
covers physician, outpatient, and some preventive services. Part C, 
also known as the Medicare Advantage program, allows beneficiaries who 
are eligible for benefits under Part A and Part B to enroll in a 
private plan, such as a health maintenance organization, preferred 
provider organization, or private fee-for-service plan, as an 
alternative to the traditional Part A and Part B programs. Finally, 
Part D is Medicare's optional outpatient prescription drug benefit 
program. 

In 2009, nearly 38 million beneficiaries age 65 and older were 
enrolled in Part A,[Footnote 16] and about 22 million (58 percent) of 
those were enrolled in Part D (see table 1).[Footnote 17] 
Approximately 9.8 million beneficiaries elected to receive their Part 
A and Part B benefits through Part C Medicare Advantage plans. 

Table 1: Medicare Enrollment, Age 65 and Older, 2009: 

Medicare coverage: Part A - hospital insurance; 
Eligibility: Automatic; 
Enrollment (in millions): 37.8. 

Medicare coverage: Part B - physician and outpatient insurance; 
Eligibility: Optional; 
Enrollment (in millions): 35.6. 

Medicare coverage: Part C - Medicare Advantage (alternative to Parts A 
and B); 
Eligibility: Optional; 
Enrollment (in millions): 9.8. 

Medicare coverage: Part D - prescription drug coverage; 
Eligibility: Optional; 
Enrollment (in millions): 21.8. 

Source: GAO analysis of CMS 2009 Data Compendium. 

[End of table] 

Part A typically has no premiums but includes deductibles and co-
payments, whereas the optional Parts B, C, and D typically require 
that beneficiaries pay premiums and share costs, including 
deductibles, co-payments, or coinsurance.[Footnote 18] For most 
physician and outpatient services covered under Part B, beneficiaries 
typically pay 20 percent of the Medicare-approved amount; however, no 
cost sharing is required for certain preventive services covered under 
Part B.[Footnote 19] For beneficiaries in Part C Medicare Advantage 
plans, beneficiary cost sharing may vary. All Medicare beneficiaries 
may elect to enroll in Part D. Medicare beneficiaries obtain Part D 
coverage by choosing from multiple competing Part D prescription drug 
plans offered by plan sponsors--often private insurers--that contract 
with CMS to offer the outpatient prescription drug benefit. Part C 
Medicare Advantage plans may also sponsor Part D prescription drug 
plans that offer outpatient prescription drug coverage to their 
members. Of the nearly 22 million beneficiaries enrolled in Part D 
prescription drug plans in 2009, about 30 percent were enrolled in 
Medicare Advantage prescription drug plans. 

At a minimum, Part D plans must offer a standard benefit established 
under the Medicare Prescription Drug, Improvement, and Modernization 
Act of 2003 (MMA)[Footnote 20] or an actuarially equivalent plan. The 
standard benefit has an annual deductible, and includes coverage up to 
a specified level of spending, a coverage gap--the so-called donut 
hole--when beneficiaries pay a greater portion of the cost of their 
drugs, and catastrophic coverage above a specified cost-sharing 
limit.[Footnote 21] Plan sponsors can offer a range of Part D plans 
that vary in the coverage provided, monthly premiums, and cost-sharing 
arrangements, such as deductibles and co-payments. 

To help defray out-of-pocket prescription drug costs for low-income 
Medicare beneficiaries, Part D offers a low-income subsidy (LIS) for 
eligible beneficiaries.[Footnote 22] LIS beneficiaries get help paying 
for their premiums and deductibles and generally have zero or nominal 
cost sharing and no coverage gap. In 2009, about 30 percent of Part D 
beneficiaries age 65 and older received the LIS.[Footnote 23] 

Medicare Coverage of Routinely Recommended Adult Vaccinations: 

Medicare coverage of vaccinations routinely recommended by ACIP for 
adults age 65 and older is divided between Part B and Part D (see 
table 2), and ACIP reviews its recommendations annually.[Footnote 24] 
As of August 2011, Part B covered the influenza and pneumococcal 
vaccines at no cost to the beneficiary, even though Part B 
beneficiaries typically pay 20 percent of the Medicare-approved amount 
for most physician and outpatient services covered under Part B. 
Vaccinations administered to treat an injury or exposure to a disease--
but not as routinely recommended preventive measures--such as a 
Td/Tdap vaccination following possible exposure to tetanus from 
stepping on a rusty nail, are also covered under Part B.[Footnote 25] 
As of August 2011, Td vaccinations that are recommended as a booster 
every 10 years and Tdap vaccinations that are recommended as a onetime 
replacement for one of the boosters, to prevent the diseases, are 
covered under Part D.[Footnote 26] Part D coverage encompasses all 
vaccinations not specifically covered by Part B, including the 
shingles vaccination, which since 2006 has been recommended for all 
adults age 60 and older (except for adults with certain symptoms or 
conditions, such as the human immunodeficiency virus).[Footnote 27] 
(See appendix II for more information on shingles.) Unlike Part B, 
Part D plans vary in their cost-sharing arrangements, including cost 
sharing for vaccinations. For beneficiaries in the coverage gap in 
2009, cost sharing could be up to 100 percent of the vaccination cost. 
All other vaccinations covered under Part D in 2011 were either not 
routinely recommended for adults age 65 and older or were recommended 
only in cases where certain risk factors were present. 

Table 2: Medicare Coverage of ACIP's Routinely Recommended Preventive 
Vaccinations for Adults Age 65 and Older, February 2011: 

Vaccine: Influenza; 
Medicare coverage: Part B; 
Recommendation: Annually. 

Vaccine: Pneumococcal; 
Medicare coverage: Part B; 
Recommendation: Once age 65 and older. 

Vaccine: Td[A]; 
Medicare coverage: Part D; 
Recommendation: One booster every 10 years. 

Vaccine: Shingles[B]; 
Medicare coverage: Part D; 
Recommendation: Once age 60 and older. 

Source: GAO analysis of Medicare coverage and ACIP recommendations as 
of February 2011. 

Notes: We did not include as "routinely recommended" the vaccinations 
that ACIP recommended only for individuals age 65 and older with 
certain risk factors, such as vaccinations to prevent measles, mumps, 
and rubella; hepatitis A; hepatitis B; and meningitis. In addition, 
although ACIP recommended the varicella (chicken pox) vaccination for 
all adults without evidence of immunity to chicken pox, being U.S.-
born prior to 1980 is considered to be evidence of immunity. ACIP also 
recommended specific vaccinations for individuals traveling to some 
foreign countries. 

[A] In 2010, ACIP recommended a onetime Tdap vaccination as a 
replacement for one Td booster for adults age 65 and older. Part B 
covers the Td or Tdap vaccination when it is related to the treatment 
of an injury or incidence of exposure; Part D covers the routinely 
recommended Td or Tdap vaccination when administered as a booster to 
prevent the diseases. 

[B] ACIP added the recommendation for the shingles vaccination for 
adults age 60 and older in 2006. 

[End of table] 

Under Part D, physicians' and pharmacies' status as "in-network" or 
"out-of-network" providers affects their ability to verify beneficiary 
coverage and bill Part D plans. Beneficiaries may receive their 
Medicare Part B-or Part D-covered vaccinations from a physician or a 
pharmacy. Part B-covered vaccinations--including those for influenza, 
pneumonia, and hepatitis B for certain individuals--have been 
traditionally provided in physicians' offices. However, pharmacies are 
playing an increasing role in providing adult vaccinations and can 
submit Part B claims to Medicare for Part B-covered vaccinations--as, 
for example, when a pharmacy offers annual influenza vaccinations. 
Part D is organized through networks of pharmacies under contract with 
prescription drug plans. As in-network providers, pharmacies typically 
have access to online, real-time systems to verify beneficiaries' Part 
D vaccination coverage, determine the required Part D cost-sharing 
amount, and bill Part D plans. However, under Part D, physician 
offices are typically considered out-of-network providers and 
generally do not have the same type of online, real-time systems 
pharmacies have to verify coverage, determine the beneficiary cost-
sharing amount, and obtain Part D reimbursement. 

About One-Tenth of Medicare Beneficiaries Have Received Shingles 
Vaccinations, about Half Have Received Td Vaccinations, and Relatively 
Few Received Them under Part D: 

National survey data from 2009 indicate that about one-tenth of the 
nearly 38 million Medicare beneficiaries have received the routinely 
recommended onetime shingles vaccination and about half are up-to-date 
with their Td vaccinations. The survey data also show that Medicare 
beneficiaries with both Part D and other insurance coverage reported 
receiving shingles and Td vaccinations at similar percentages as 
beneficiaries with other types of coverage. Medicare Part D data for 
2007 through 2009 indicate that relatively few Part D beneficiaries 
received shingles and Td vaccinations under Part D. These data suggest 
that some Medicare beneficiaries received their vaccinations outside 
of Part D, either prior to enrolling, using other health coverage, or 
paying out of pocket. 

NHIS Data Indicate That 11 Percent of Medicare Beneficiaries Have 
Received a Shingles Vaccination and 53 Percent Have Received a Td 
Vaccination: 

NHIS data from 2009 indicate that 11 percent of Medicare 
beneficiaries[Footnote 28] reported ever receiving a shingles 
vaccination[Footnote 29] and 53 percent reported receiving a Td 
vaccination in the previous 10 years--the time interval recommended 
between boosters. The shingles vaccine has been available since 2006, 
and the percentage of adults age 65 and older reporting ever receiving 
this vaccination has increased since 2007 (see table 3). Using the 
2008 NHIS data as a baseline, HHS set a national target for the 
percentage of adults age 60 and older who report ever receiving the 
shingles vaccination of 30 percent by 2020.[Footnote 30] 

Table 3: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving Shingles Vaccination or Receiving Td Vaccination in Previous 
10 Years, 2007 through 2009: 

Vaccination: Shingles[A]; 
2007: 2.3%; 
2008: 7.6%; 
2009: 11.0%. 

Vaccination: Td[B]; 
2007: 44.1%; 
2008: 51.9%; 
2009: 52.8%. 

Source: GAO analysis of CDC National Immunization Survey (2007) and 
NHIS (2008 and 2009). 

Note: The age 65 and older population surveyed closely corresponds to 
the Medicare population. 

[A] National estimates of the percentage of adults age 65 and older 
who reported ever receiving a shingles vaccination. 

[B] National estimates of the percentage of adults age 65 and older 
who reported receiving a Td vaccination in the previous 10 years. Data 
include Td vaccinations administered as a treatment or as a preventive 
measure. 

[End of table] 

NHIS data can also provide national estimates of adults who reported 
receiving shingles or Td vaccinations based on type of insurance 
coverage. NHIS data indicate that Medicare beneficiaries with both 
Part D and other insurance coverage reported receiving shingles or Td 
vaccinations at similar percentages as beneficiaries with other types 
of coverage (see table 4). (See appendix III for additional NHIS data 
on shingles and Td vaccination by selected demographic groups.) 

Table 4: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving Shingles Vaccination or Receiving Td Vaccination in Previous 
10 Years, by Insurance Coverage, 2009: 

Vaccination: Shingles[B]; 
All respondents: 11.0%; 
Without Part D coverage: 
No other coverage[A]: 10.7%; 
With private or other coverage[A]: 13.4%; 
With Part D coverage: 
No other coverage: 11.5%; 
With private or other coverage[A]: 14.6%. 

Vaccination: Td[C]; 
All respondents: 52.8%; 
Without Part D coverage: 
No other coverage[A]: 52.8%; 
With private or other coverage[A]: 54.8%; 
With Part D coverage: 
No other coverage: 52.6%; 
With private or other coverage[A]: 56.0%. 

Source: GAO analysis of CDC NHIS (2009). 

Note: The age 65 and older population surveyed closely corresponds to 
the Medicare population. 

[A] Other coverage includes Medicaid, a state-sponsored or other 
government-sponsored health plan, or a military plan. 

[B] National estimates of the percentage of adults age 65 and older 
who reported ever receiving a shingles vaccination. 

[C] National estimates of the percentage of adults age 65 and older 
who reported receiving a Td vaccination in the previous 10 years. Data 
include Td vaccinations administered as a treatment or as a preventive 
measure. 

[End of table] 

National survey data also show that some individuals obtain shingles 
or Td vaccinations prior to age 65, the typical enrollment age for 
Medicare. NHIS data for 2009 show that almost 8 percent of adults age 
60 to 64 reported that they had received the onetime shingles 
vaccination. For Td, the reported coverage rate is even higher--NHIS 
data for 2009 show that almost 60 percent of adults age 60 to 64 
reported being up-to-date with their Td vaccinations. 

Medicare Data for 2007 through 2009 Indicate That Relatively Few 
Beneficiaries Received Shingles and Td/Tdap Vaccinations under Part D: 

Medicare Part D data for 2007 through 2009 indicate that relatively 
few Part D beneficiaries received shingles and Td/Tdap vaccinations 
under Part D.[Footnote 31] Specifically, the data show that Part D 
plans reimbursed shingles vaccinations for about 5 percent of Part D 
beneficiaries and Td/Tdap vaccinations for less than 1 percent of Part 
D beneficiaries.[Footnote 32] Few beneficiaries had other vaccinations 
reimbursed through Part D, as shingles vaccinations accounted for 89 
percent of all Part D-reimbursed vaccinations, and Td/Tdap 
vaccinations accounted for 10 percent of Part D-reimbursed 
vaccinations during this period.[Footnote 33] 

Part D data also show that the percentages of beneficiaries with 
vaccinations reimbursed by Part D varied slightly among different 
groups of beneficiaries, specifically, between those in Medicare 
Advantage prescription drug plans and those in other Part D 
prescription drug plans and between LIS and non-LIS beneficiaries. For 
example, in 2009, about 30 percent of Part D beneficiaries were in 
Medicare Advantage prescription drug plans, and a slightly higher 
percentage of these beneficiaries had shingles and Td/Tdap 
vaccinations reimbursed by Part D plans than beneficiaries in other 
Part D prescription drug plans (see table 5). LIS beneficiaries--who 
make up approximately 30 percent of Part D beneficiaries--had Part D 
reimburse for shingles and Td/Tdap vaccinations less frequently than 
those Part D beneficiaries who did not receive the subsidy. (See 
appendix III for additional Part D data on vaccination by selected 
demographic groups.) 

Table 5: Vaccinations Reimbursed by Part D for Medicare Beneficiaries, 
by Part D Plan Type and LIS Status, 2007 through 2009: 

All beneficiaries: 
Percentage of Part D beneficiaries with shingles vaccinations under 
Part D: 4.59; 
Percentage of Part D beneficiaries with Td/Tdap vaccinations under 
Part D[A]: 0.49. 

By plan type: Medicare Advantage prescription drug plans; 
Percentage of Part D beneficiaries with shingles vaccinations under 
Part D: 5.33; 
Percentage of Part D beneficiaries with Td/Tdap vaccinations under 
Part D[A]: 1.44. 

By plan type: By LIS status: Other Part D prescription drug plans; 
Percentage of Part D beneficiaries with shingles vaccinations under 
Part D: By LIS status: 4.27; 
Percentage of Part D beneficiaries with Td/Tdap vaccinations under 
Part D[A]: By LIS status: 0.09. 

By LIS status: Non-LIS; 
Percentage of Part D beneficiaries with shingles vaccinations under 
Part D: 5.93; 
Percentage of Part D beneficiaries with Td/Tdap vaccinations under 
Part D[A]: 0.63. 

By LIS status; LIS; 
Percentage of Part D beneficiaries with shingles vaccinations under 
Part D: Percentage of Part D beneficiaries with shingles vaccinations 
under Part D: 1.87; 
Percentage of Part D beneficiaries with Td/Tdap vaccinations under 
Part D[A]: Percentage of Part D beneficiaries with Td/Tdap 
vaccinations under Part D[A]: 0.21. 

Source: GAO analysis of 2007 through 2009 Medicare Part D data. 

Note: We analyzed Part D data for beneficiaries age 65 and older 
enrolled in a Part D plan at any time from 2007 through 2009, 
excluding those enrolled in employer plans, religious fraternal 
benefit plans, CMS demonstrations, and programs of all-inclusive care 
for the elderly. 

[A] To determine the percentage of Part D beneficiaries reimbursed for 
vaccinations that protect against tetanus and diphtheria, both with 
and without the pertussis component, we examined Part D data for both 
Td and Tdap. 

[End of table] 

In addition to their Medicare coverage, beneficiaries may have other 
coverage that could help pay for routinely recommended vaccinations. 
The Medicare Payment Advisory Commission (MedPAC) reported that in 
2009, 90 percent of Medicare beneficiaries had drug coverage, 
including employer-based or other federal coverage, that was at least 
as generous as Part D's defined standard benefit, which covers 
routinely recommended vaccinations not covered by Part B.[Footnote 34] 

A Multitude of Factors Affect Beneficiaries' Access to Part D-Covered 
Vaccinations, Particularly for Shingles: 

On the basis of our physician, pharmacy, and SHIP surveys, we 
identified a multitude of factors that affect Part D beneficiaries' 
access to routinely recommended Part D-covered vaccinations. Most 
physicians do not stock the shingles vaccine due to factors such as 
the cost of purchasing a supply of the vaccine and administrative 
challenges related to reimbursement. In comparison with other 
vaccinations, physicians recommend shingles vaccinations less 
frequently, and even when a shingles vaccination is recommended by a 
physician, beneficiaries may decide not to get it. Additionally, most 
pharmacies do not stock either the shingles or the Td/Tdap vaccines. 
Finally, some beneficiaries may find it difficult to afford the cost-
sharing requirements or, if their physicians do not bill Part D plans, 
to pay the full cost up front for Part D vaccinations. 

Most Physicians Do Not Stock the Shingles Vaccine, in Contrast to 
Other Vaccines, Due to Cost and Part D Administrative Challenges: 

Based on our 2010 survey of physicians, we estimate that nearly 7 in 
10 primary care physicians--the primary providers of preventive 
services to Medicare beneficiaries--do not stock the Part D-covered 
shingles vaccine.[Footnote 35] (See figure 1.) In contrast, we 
estimate that about 2 in 10 physicians do not stock Td/Tdap vaccines, 
and about 1 in 10 does not stock the Part B-covered pneumococcal 
vaccine. [Footnote 36] 

Figure 1: Physicians Stocking the Shingles, Td/Tdap, and Pneumococcal 
Vaccines: 

[Refer to PDF for image: 3 pie-charts] 

Shingles: 
Stock the vaccine: 31%; 
Do not stock the vaccine: 69%. 

Td/Tdap: 
Stock the vaccine: 83%; 
Do not stock the vaccine: 17%. 

Pneumococcal: 
Stock the vaccine: 91%; 
Do not stock the vaccine: 9%. 

Source: GAO 2010 Physician Survey. 

Note: The sampling frame for our survey included practicing family and 
internal medicine physicians in the United States who were not federal 
employees and who provided primary care to Medicare beneficiaries age 
65 and older. 

[End of figure] 

One factor that is related to whether a physician stocks the shingles 
vaccine is the size of the physician's practice. Our 2010 survey of 
physicians found that smaller practices stock the shingles vaccine 
less frequently than larger practices. (See figure 2.) Smaller 
practices with one or two physicians serve as the setting for nearly 
half of primary care physicians, according to 2005-2006 data from 
CDC,[Footnote 37] and these practices are more frequently composed of 
a larger proportion of beneficiaries age 65 and older than larger 
practices, according to our survey. Thirty-seven percent of smaller 
practices had Medicare beneficiaries age 65 and older making up more 
than half of their patients, compared to 26 percent of practices with 
3 to 10 physicians, and 21 percent of practices with more than 10 
physicians.[Footnote 38] Thus the practices that are more likely to 
have a higher proportion of Medicare beneficiaries may be less likely 
to stock the shingles vaccine. 

Figure 2: Physicians Stocking the Shingles, Td/Tdap, and Pneumococcal 
Vaccines, by Practice Size: 

[Refer to PDF for image: vertical bar graph] 

Shingles: 
1 to 2 physicians: 20%; 
3 to 10 physicians: 33%; 
More than 10 physicians: 54%[A]; 
All physicians: 31%. 

Td/Tdap: 
1 to 2 physicians: 75%; 
3 to 10 physicians: 84%[A]; 
More than 10 physicians: 96%; 
All physicians: 83%. 

Pneumococcal: 
1 to 2 physicians: 84%; 
3 to 10 physicians: 97%; 
More than 10 physicians: 98%; 
All physicians: 91%. 

Source: GAO 2010 Physician Survey. 

Note: The sampling frame for our survey included practicing family and 
internal medicine physicians in the United States who were not federal 
employees and who provided primary care to Medicare beneficiaries age 
65 and older. 

[A] Estimate has a margin of error above plus or minus 8 percentage 
points at the 95 percent confidence level. 

[End of figure] 

Our survey also found that most physicians who do not stock the 
shingles vaccine themselves rely on pharmacies to stock it. As shown 
in figure 3, nearly 8 in 10 physicians who do not stock the shingles 
vaccine refer beneficiaries to a pharmacy to purchase it. Nearly half 
of those physicians administer the purchased shingles vaccine in their 
offices.[Footnote 39] 

Figure 3: Referral Practices of Physicians Who Do Not Stock the 
Shingles Vaccine: 

[Refer to PDF for image: pie-chart] 
 
Refer beneficiaries to a pharmacy  to purchase vaccine and it is 
administered by physician: 38%; 
Refer beneficiaries to a pharmacy for vaccination: 40%; 
Other: 22%. 

Nearly 8 in 10 physicians (78%) refer beneficiaries to a pharmacy.  
   
Source: GAO 2010 Physician Survey. 

Notes: Other includes physicians who refer beneficiaries to another 
physician or to a public health department for vaccination or who 
provided a different response. 

[End of figure] 

The sampling frame for our survey included practicing family and 
internal medicine physicians in the United States who were not federal 
employees and who provided primary care to Medicare beneficiaries age 
65 and older. 

Physicians who do not stock the shingles vaccine cited a multitude of 
factors as barriers to stocking, administering, or recommending the 
vaccine.[Footnote 40] (See table 6.) Our survey also found that most 
physicians (82 percent) identified more than one factor as a major 
barrier. The cumulative effect of these barriers may deter physicians 
from stocking the vaccine. 

Table 6: Barriers Cited by Physicians Who Do Not Stock the Shingles 
Vaccine: 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 94 (92, 96); 
Major barrier percentage (lower bound, upper bound): 76 (71, 82); 
Minor barrier percentage (lower bound, upper bound): 18 (13, 22). 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 90 (88, 93); 
Major barrier percentage (lower bound, upper bound): 79 (75, 83); 
Minor barrier percentage (lower bound, upper bound): 11 (7, 16). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 90 (86, 94); 
Major barrier percentage (lower bound, upper bound): 70 (66, 74); 
Minor barrier percentage (lower bound, upper bound): 20 (15, 24). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 86 (84, 88); 
Major barrier percentage (lower bound, upper bound): 65 (59, 70); 
Minor barrier percentage (lower bound, upper bound): 22 (17, 26). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 85 (80, 90); 
Major barrier percentage (lower bound, upper bound): 66 (59, 72); 
Minor barrier percentage (lower bound, upper bound): 19 (15, 24). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 83 (78, 88); 
Major barrier percentage (lower bound, upper bound): 59 (53, 64); 
Minor barrier percentage (lower bound, upper bound): 24 (20, 28). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 58 (53, 63); 
Major barrier percentage (lower bound, upper bound): 21 (16, 26); 
Minor barrier percentage (lower bound, upper bound): 37 (32, 42). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 58 (52, 64); 
Major barrier percentage (lower bound, upper bound): 27 (23, 31); 
Minor barrier percentage (lower bound, upper bound): 31 (26, 35). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 56 (50, 62); 
Major barrier percentage (lower bound, upper bound): 30 (26, 34); 
Minor barrier percentage (lower bound, upper bound): 26 (21, 31). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 47 (41, 54); 
Major barrier percentage (lower bound, upper bound): 10 (6, 14); 
Minor barrier percentage (lower bound, upper bound): 37 (31, 43). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 46 (40, 52); 
Major barrier percentage (lower bound, upper bound): 10 (5, 15); 
Minor barrier percentage (lower bound, upper bound): 36 (31, 42). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 41 (37, 46); 
Major barrier percentage (lower bound, upper bound): 23 (20, 26); 
Minor barrier percentage (lower bound, upper bound): 18 (13, 23). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 30 (25, 35); 
Major barrier percentage (lower bound, upper bound): 8 (5, 12); 
Minor barrier percentage (lower bound, upper bound): 22 (17, 26). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 18 (13, 24); 
Major barrier percentage (lower bound, upper bound): 3 (2, 4); 
Minor barrier percentage (lower bound, upper bound): 15 (10, 20). 

Source: GAO 2010 Physician Survey. 

Notes: Respondents were asked to classify the 14 listed factors as a 
major barrier, a minor barrier, or not a barrier to stocking, 
administering, or recommending the shingles vaccine. 

The sampling frame for our survey included practicing family and 
internal medicine physicians in the United States who were not federal 
employees and who provided primary care to Medicare beneficiaries age 
65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major and minor barriers may not equal 
the total percentage due to rounding. 

[End of table] 

Of the 14 factors that physicians could choose to cite as barriers on 
our survey, physicians who do not stock the shingles vaccine often 
cited reimbursement issues, the cost of purchasing a vaccine stock, 
and multiple administrative challenges related to Part D as barriers. 
About 9 in 10 physicians who do not stock the shingles vaccine cited 
inconsistent and low reimbursement rates and the cost of purchasing a 
stock of the vaccine as barriers. As of December 2009, the retail 
price of the shingles vaccine, which is the highest price per dose for 
a routinely recommended adult vaccine, was about $154 per dose when 
purchased in a 10-dose package, or $162 for a single dose.[Footnote 
41] Physicians who do not stock the vaccine also cited concerns about 
administrative challenges related to reimbursement. Because Part D 
reimbursement rates may vary based on beneficiaries' Part D plans, 
without real-time access to beneficiary coverage information, 
physicians may not know how much Part D plans will reimburse for 
shingles vaccinations. In addition, more than 8 in 10 physicians cited 
the amount of time and effort needed to identify beneficiaries' 
coverage and submit claims for reimbursements as a barrier.[Footnote 
42] 

[Side bar: 
Shingles Vaccine Supply: 
The sole manufacturer of the shingles vaccine for the U.S. market has 
reported that since the vaccine first came on the U.S. market in 2006, 
it has periodically experienced difficulty meeting demand, and the 
short supply has necessitated some back orders. The manufacturer, 
which also produces the chicken pox vaccine, has cited multiple 
reasons for the limited supply. For example, the shingles vaccine 
contains the same key ingredient as the chicken pox vaccine, which is 
routinely recommended for children, and in 2006 ACIP changed the
recommendation for the chicken pox vaccine from one dose to two. In 
response, the shingles vaccine manufacturer assigned a higher priority 
to the production of the chicken pox vaccine, which contributed to the 
supply challenges for the shingles vaccine. The manufacturer has also 
reported delays in manufacturing caused by difficulties in production, 
although manufacturer officials expected an increase in production for 
2011. 

CDC officials told us that neither CDC nor the manufacturer has 
heavily promoted the shingles vaccine because of the limited supply, 
likely affecting beneficiaries' awareness of and demand for it. In 
addition, the manufacturer's ability to market a refrigerated 
formulation of the shingles vaccine has also been affected by the 
limited supply of a key ingredient. According to the manufacturer, a 
refrigerated formulation of the vaccine licensed in the United States 
was not being marketed as of June 2011 because it requires 
significantly more of the key ingredient than the frozen vaccine. The 
limited supply was also factored into ACIP's decision making for its 
shingles vaccination recommendation. The Food and Drug Administration 
approved the use of shingles vaccine for adults age 50 and older in 
March 2011. In June 2011, however, ACIP decided not to expand its 
recommendation to include adults age 50 to 59, in part because of 
inadequate vaccine supply. 

The supply issues contribute to the challenges of identifying the 
barriers to shingles vaccinations. As a CDC shingles expert who 
participated in our IOM-facilitated panel discussion noted, it is very 
difficult to provide empirical data on the barriers to Part
D vaccinations because they are so complex. The expert described the 
situation as a "witch's brew" of barriers to shingles vaccinations, 
including limited supply, administrative challenges, limited marketing 
of the vaccine, and insufficient education for providers and 
beneficiaries. End of side bar] 

Other frequently cited barriers in our physician survey included those 
associated with beneficiaries' ability to pay for, and their demand 
for, shingles vaccinations. More than 8 in 10 physicians cited 
beneficiaries' difficulty affording the cost sharing and 
beneficiaries' lack of Part D coverage or other insurance as barriers. 
And nearly 6 in 10 physicians cited a lack of, or uncertain, 
beneficiary demand for shingles vaccinations as a barrier. 

Less frequently cited barriers included logistical concerns. Limited 
supply of the shingles vaccine may have deterred physicians from 
trying to stock it. Nearly 6 in 10 physicians who do not stock the 
shingles vaccine cited trouble stocking the vaccine due to the limited 
supply and order backlogs as a barrier. In addition, unlike other 
routinely recommended adult vaccines, the shingles vaccine must remain 
frozen until just prior to administration, and not all physicians have 
appropriate equipment to stock frozen vaccines.[Footnote 43] More than 
4 in 10 physicians who do not stock the shingles vaccine cited storage 
difficulties as a barrier. 

In addition to stocking the shingles vaccine less frequently than 
other vaccines, physicians recommend shingles and Td/Tdap vaccinations 
to beneficiaries less frequently than the Part B-covered pneumococcal 
vaccination. (See figure 4.) According to our survey, 2 in 3 
physicians usually or always recommend the shingles vaccination, and 3 
in 4 physicians usually or always recommend Td/Tdap vaccination. In 
comparison, nearly all physicians--more than 95 percent--usually or 
always recommend the pneumococcal vaccination. 

Figure 4: Physician Recommendations for the Shingles, Td/Tdap, and 
Pneumococcal Vaccines: 

[Refer to PDF for image: 3 pie-charts] 

Shingles: 
Always recommend the vaccine: 33%; 
Usually recommend the vaccine: 35%; 
Recommend the vaccine about half the time or less: 32%. 

Td/Tdap: 
Always recommend the vaccine: 46%; 
Usually recommend the vaccine: 28%; 
Recommend the vaccine about half the time or less: 26%. 

Pneumococcal: 
Always recommend the vaccine: 78%; 
Usually recommend the vaccine: 19%; 
Recommend the vaccine about half the time or less: 4%. 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Percentages may not total to 100 percent due to rounding. 

[End of figure] 

Even when physicians recommend Part D-covered vaccinations, 
beneficiaries often decline them, particularly shingles vaccinations. 
According to our survey, after physicians recommend vaccinations, 
beneficiaries more frequently decline shingles vaccinations than Td/ 
Tdap and pneumococcal vaccinations. More than 6 in 10 physicians 
report that beneficiaries decline shingles vaccinations about half the 
time or more. (See figure 5.) In comparison, 1 in 10 physicians report 
that beneficiaries decline pneumococcal vaccinations half the time or 
more. 

Figure 5: Beneficiary Declinations of Shingles, Td/Tdap, and 
Pneumococcal Vaccinations after Physicians Have Recommended Them: 

[Refer to PDF for image: 3 pie-charts] 

Shingles: 
Beneficiaries never or occasionally decline the vaccine: 32%; 
Beneficiaries decline the vaccine about half the time or more: 62%; 
Don't know: 6%. 

Td/Tdap: 
Beneficiaries never or occasionally decline the vaccine: 64%; 
Beneficiaries decline the vaccine about half the time or more: 32%; 
Don't know: 4%. 

Pneumococcal: 
Beneficiaries never or occasionally decline the vaccine: 89; 
Beneficiaries decline the vaccine about half the time or more: 10%; 
Don't know: 1%. 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Excludes physicians who never recommend shingles, Td/Tdap, or 
pneumococcal vaccinations. For each of the vaccinations, less than 2 
percent of physicians never recommend the vaccination. 

[End of figure] 

Most Pharmacies Do Not Stock Shingles or Td/Tdap Vaccines, and Many 
That Stock the Shingles Vaccine Face Limited Supply: 

Based on our 2010 survey of pharmacies, we estimate that nearly 7 in 
10 pharmacies do not stock the shingles vaccine, nearly 8 in 10 do not 
stock Td/Tdap vaccines, and more than 5 in 10 do not stock the 
pneumococcal vaccine.[Footnote 44] (See figure 6.) Instead, pharmacies 
most commonly refer beneficiaries to physicians for their 
vaccinations. Although stakeholders told us that pharmacies are 
increasingly serving as an access point for Medicare beneficiaries' 
routinely recommended vaccinations, some pharmacies do not play an 
active role in providing the vaccines. Nearly 5 in 10 pharmacies do 
not stock any of the three vaccines, and more than 3 in 10 do not 
regularly offer or recommend vaccinations to beneficiaries.[Footnote 
45] 

Figure 6: Pharmacies Stocking the Shingles, Td/Tdap, and Pneumococcal 
Vaccines: 

[Refer to PDF for image: 3 pie-charts] 

Shingles: 
Stock the vaccine: 35%; 
Do not stock; refer beneficiaries to a physician for vaccination: 40%; 
Do not stock; other: 26%. 

Td/Tdap: 
Stock the vaccine: 21%; 
Do not stock; refer beneficiaries to a physician for vaccination: 60%; 
Do not stock; other: 18%. 

Pneumococcal: 
Stock the vaccine: 46%; 
Do not stock; refer beneficiaries to a physician for vaccination: 40%; 
Do not stock; other: 14%. 

Source: GAO 2010 Physician Survey. 

Notes: Other includes pharmacies that refer beneficiaries to other 
pharmacies or to a public health department for vaccination, or that 
provided a different response. 

The sampling frame for our survey included pharmacies in the United 
States that were not operated by a federal agency and that served 
Medicare beneficiaries age 65 and older. 

Percentages may not total to 100 percent due to rounding. 

[End of figure] 

Moreover, not all pharmacies that stock vaccines administer them. 
[Footnote 46] Based on our pharmacy survey, 2 in 10 pharmacies that 
stock the shingles vaccine and nearly 1 in 10 pharmacies that stock 
the Td/Tdap vaccines do not administer them.[Footnote 47] 

Based on our pharmacy survey, pharmacies that do not stock the 
shingles vaccine cited a multitude of factors as barriers to stocking 
the vaccine. (See table 7.) Of the 15 factors that pharmacies could 
choose to cite as barriers, pharmacies that do not stock the shingles 
vaccine often cited beneficiaries' difficulty affording cost sharing 
and storage difficulties as barriers, with about 7 in 10 citing each 
as a barrier. In addition, more than 6 in 10 cited inconsistent Part D 
reimbursement rates as a barrier. 

Table 7: Barriers Cited by Pharmacies That Do Not Stock the Shingles 
Vaccine: 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 69 (64, 74); 
Major barrier percentage (lower bound, upper bound): 33 (18, 48); 
Minor barrier percentage (lower bound, upper bound): 37 (22, 51). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 69 (54, 83); 
Major barrier percentage (lower bound, upper bound): 59 (39, 78); 
Minor barrier percentage (lower bound, upper bound): 10 (0, 23). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 65 (61, 70); 
Major barrier percentage (lower bound, upper bound): 45 (30, 60); 
Minor barrier percentage (lower bound, upper bound): 20 (6, 34). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 59 (55, 62); 
Major barrier percentage (lower bound, upper bound): 27 (13, 42); 
Minor barrier percentage (lower bound, upper bound): 31 (16, 46). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 58 (44, 72); 
Major barrier percentage (lower bound, upper bound): 45 (31, 58); 
Minor barrier percentage (lower bound, upper bound): 13 (9, 17). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 57 (38, 76); 
Major barrier percentage (lower bound, upper bound): 33 (14, 52); 
Minor barrier percentage (lower bound, upper bound): 24 (20, 28). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 56 (42, 70); 
Major barrier percentage (lower bound, upper bound): 37 (18, 56); 
Minor barrier percentage (lower bound, upper bound): 19 (6, 33). 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 49 (30, 69); 
Major barrier percentage (lower bound, upper bound): 25 (11, 39); 
Minor barrier percentage (lower bound, upper bound): 24 (12, 36). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 49 (30, 69); 
Major barrier percentage (lower bound, upper bound): 21 (6, 35); 
Minor barrier percentage (lower bound, upper bound): 29 (16, 41). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 47 (27, 68); 
Major barrier percentage (lower bound, upper bound): 39 (20, 58); 
Minor barrier percentage (lower bound, upper bound): 8 (5, 12). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 43 (29, 58); 
Major barrier percentage (lower bound, upper bound): 9 (0, 24); 
Minor barrier percentage (lower bound, upper bound): 34 (16, 52). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 37 (22, 53); 
Major barrier percentage (lower bound, upper bound): 10 (0, 26); 
Minor barrier percentage (lower bound, upper bound): 27 (8, 47). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 19 (8, 31); 
Major barrier percentage (lower bound, upper bound): 16 (6, 26); 
Minor barrier percentage (lower bound, upper bound): 3 (1, 6). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 16 (4, 29); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 15 (3, 27). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 16 (3, 28); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 14 (2, 25). 

Source: GAO 2010 Pharmacy Survey. 

Notes: Respondents were asked to classify the 15 listed factors as a 
major barrier, a minor barrier, or not a barrier to stocking, 
administering, or recommending the shingles vaccine. 

The sampling frame for our survey included pharmacies in the United 
States that were not operated by a federal agency and that served 
Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major and minor barriers may not equal 
the total percentage due to rounding. 

[End of table] 

In addition, our pharmacy survey found that those pharmacies that do 
stock the shingles vaccine have faced difficulties obtaining the 
vaccine due to limited supply. For pharmacies that do stock the 
shingles vaccine, more than 8 in 10 cited trouble stocking the vaccine 
caused by vaccine shortages or order backlogs as a barrier. 

Pharmacies that do not stock Td/Tdap vaccines also cited a number of 
factors as barriers to stocking the vaccine. Lack of beneficiary 
demand for the Td/Tdap vaccine and inconsistent Part D reimbursement 
rates were often cited as barriers.[Footnote 48] (See table 8.) 

Table 8: Barriers Cited by Pharmacies That Do Not Stock the Td/Tdap 
Vaccines: 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 64 (49, 79); 
Major barrier percentage (lower bound, upper bound): 40 (27, 53); 
Minor barrier percentage (lower bound, upper bound): 24 (15, 34). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 62 (53, 71); 
Major barrier percentage (lower bound, upper bound): 39 (32, 45); 
Minor barrier percentage (lower bound, upper bound): 24 (19, 28). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 58 (51, 65); 
Major barrier percentage (lower bound, upper bound): 37 (27, 46); 
Minor barrier percentage (lower bound, upper bound): 21 (16, 27). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 57 (49, 66); 
Major barrier percentage (lower bound, upper bound): 36 (29, 43); 
Minor barrier percentage (lower bound, upper bound): 21 (17, 25). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 54 (45, 62); 
Major barrier percentage (lower bound, upper bound): 22 (9, 36); 
Minor barrier percentage (lower bound, upper bound): 31 (18, 45). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 51 (44, 58); 
Major barrier percentage (lower bound, upper bound): 34 (23, 44); 
Minor barrier percentage (lower bound, upper bound): 17 (13, 21). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 42 (33, 51); 
Major barrier percentage (lower bound, upper bound): 14 (1, 27); 
Minor barrier percentage (lower bound, upper bound): 28 (12, 44). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 37 (30, 44); 
Major barrier percentage (lower bound, upper bound): 17 (3, 31); 
Minor barrier percentage (lower bound, upper bound): 20 (7, 32). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 36 (20, 51); 
Major barrier percentage (lower bound, upper bound): 12 (0, 25); 
Minor barrier percentage (lower bound, upper bound): 24 (11, 36). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 36 (19, 53); 
Major barrier percentage (lower bound, upper bound): 13 (0, 26); 
Minor barrier percentage (lower bound, upper bound): 23 (9, 37). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 30 (20, 40); 
Major barrier percentage (lower bound, upper bound): 26 (16, 35); 
Minor barrier percentage (lower bound, upper bound): 5 (3, 7). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 28 (15, 40); 
Major barrier percentage (lower bound, upper bound): 5 (0, 11); 
Minor barrier percentage (lower bound, upper bound): 22 (10, 35). 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 25 (12, 38); 
Major barrier percentage (lower bound, upper bound): 14 (2, 27); 
Minor barrier percentage (lower bound, upper bound): 11 (6, 15). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 10 (7, 13); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 9 (7, 10). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 10 (7, 13); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 8 (7, 10). 

Source: GAO 2010 Pharmacy Survey. 

Notes: Respondents were asked to classify the 15 listed factors as a 
major barrier, a minor barrier, or not a barrier to stocking, 
administering, or recommending the Td/Tdap vaccines. 

The sampling frame for our survey included pharmacies in the United 
States that were not operated by a federal agency and that served 
Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major and minor barriers may not equal 
the total percentage due to rounding. 

[End of table] 

Beneficiaries Face Difficulties Accessing Part D Vaccinations, 
Particularly for Shingles, Due to Multiple Factors, Including Cost 
Concerns: 

According to our physician survey, Part D beneficiaries most commonly 
declined shingles vaccinations due to difficulties affording it. We 
estimate that about half of physicians who recommended a vaccination 
reported having had beneficiaries decline shingles vaccinations due to 
a lack of insurance coverage and about half had beneficiaries decline 
vaccinations due to difficulty affording cost sharing. Other reasons 
cited by physicians for beneficiaries declining the shingles vaccine 
include concerns about the vaccine's safety and efficacy and the need 
to obtain the vaccine outside of their physician's office (see 
appendix IV for additional information from our physician survey). 

Respondents to our SHIP survey reported that Part D beneficiaries 
faced a number of difficulties when seeking Part D-covered 
vaccinations. One of the primary roles of the SHIPs is to help 
beneficiaries understand their Medicare coverage. With Medicare 
coverage of vaccinations divided between Parts B and D, almost all 
SHIPs--47 of 51--reported helping beneficiaries understand whether a 
vaccination is covered under Part B or Part D, and 38 SHIPs reported 
helping beneficiaries understand their cost sharing for Part D-covered 
vaccinations, which can vary by plan (see appendix VI for additional 
information from our SHIP survey). 

SHIPs also reported that shingles vaccinations caused more 
difficulties for beneficiaries than did Td/Tdap or Part B-covered 
pneumococcal vaccinations.[Footnote 49] (See table 9.) Beneficiaries' 
difficulty understanding Medicare coverage and difficulty affording 
cost sharing and up-front costs were among the difficulties SHIPs 
reported more frequently for the shingles vaccination. Other 
difficulties reported by the SHIPs related to providers not stocking 
or administering the shingles vaccine, such as beneficiaries' concerns 
about having to transport the shingles vaccine from a pharmacy to 
their physician, and difficulties caused by their physician not 
stocking the vaccine or their pharmacy not administering the vaccine. 

Table 9: Number of SHIPs Reporting Beneficiary Difficulties Accessing 
Shingles, Td/Tdap, and Pneumococcal Vaccinations: 

Beneficiary difficulties: Do not know whether vaccination is covered 
by Medicare; 
Shingles: 36; 
Td/Tdap: 16; 
Pneumococcal: 20. 

Beneficiary difficulties: Concerns about having to transport the 
vaccine from a pharmacy to a physician to be administered; 
Shingles: 24; 
Td/Tdap: 3; 
Pneumococcal: 1. 

Beneficiary difficulties: Difficulty affording cost sharing for 
vaccination; 
Shingles: 20; 
Td/Tdap: 2; 
Pneumococcal: N/A[A]. 

Beneficiary difficulties: Physician does not stock the vaccine; 
Shingles: 19; 
Td/Tdap: 0; 
Pneumococcal: 2. 

Beneficiary difficulties: Difficulty affording up-front costs of 
vaccination when responsible for pursuing reimbursement; 
Shingles: 18; 
Td/Tdap: 2; 
Pneumococcal: 3. 

Beneficiary difficulties: Pharmacy does not administer the vaccine; 
Shingles: 17; 
Td/Tdap: 1; 
Pneumococcal: 4. 

Beneficiary difficulties: Difficulty pursuing reimbursement for 
vaccination; 
Shingles: 14; 
Td/Tdap: 3; 
Pneumococcal: 4. 

Beneficiary difficulties: Pharmacy does not stock the vaccine; 
Shingles: 10; 
Td/Tdap: 3; 
Pneumococcal: 2. 

Beneficiary difficulties: Do not have Part D or other insurance 
coverage for vaccination; 
Shingles: 10; 
Td/Tdap: 3; 
Pneumococcal: N/A[A]. 

Beneficiary difficulties: Physician does not administer the vaccine; 
Shingles: 9; 
Td/Tdap: 2; 
Pneumococcal: 2. 

Source: GAO 2010 SHIP Survey. 

Notes: SHIPs were given a list of potential beneficiary difficulties 
and were asked to select the ones where they had encountered 
beneficiaries experiencing difficulty. 

All 51 SHIPs responded to the GAO survey. 

[A] Nearly all Medicare beneficiaries have Part B coverage for 
pneumococcal vaccinations, which covers the vaccination with no 
beneficiary cost sharing. 

[End of table] 

Medicare data indicate that Part D cost sharing, particularly for the 
shingles vaccination, can be significant. Based on our analysis of 
Part D data, we found that in 2009, non-LIS Part D beneficiaries who 
had a shingles vaccination reimbursed by Part D were still responsible 
for cost sharing that averaged $57 for a shingles vaccination and $25 
for a Td/Tdap vaccination, with cost sharing ranging as high as $195 
for a shingles vaccination.[Footnote 50] (See table 10.) In contrast, 
beneficiaries have no cost sharing for pneumococcal vaccinations, 
which are covered under Part B (see appendix VII for more information 
on beneficiaries' cost sharing for shingles and Td/Tdap vaccinations). 
The costs we found in our analysis are higher than those generally 
found to be acceptable to beneficiaries in a 2008 study of primary 
care physicians regarding shingles vaccination recommendations and 
barriers. That study reported that more than 7 in 10 physicians 
responded that their patients would be willing to spend no more than 
$29 in cost sharing for a shingles vaccination.[Footnote 51] 

Table 10: Cost Sharing and Retail Prices for the Shingles and Tetanus 
Vaccines, 2009: 

Vaccine: Shingles; 
Average cost sharing[A]: $57; 
Median cost sharing[A]: $39; 
Range of cost sharing[A]: $0-$195; 
Approximate 2009 retail price[B]: $154. 

Vaccine: Tetanus (Td/Tdap)[C]; 
Average cost sharing[A]: $25; 
Median cost sharing[A]: $27; 
Range of cost sharing[A]: $0-$70; 
Approximate 2009 retail price[B]: $18 (Td) $37 (Tdap). 

Source: GAO analysis of 2009 Medicare Part D data and CDC data. 

Note: We analyzed Part D data for beneficiaries age 65 and older, 
excluding beneficiaries who received the LIS and those enrolled in 
employer plans, religious fraternal benefit plans, CMS demonstrations, 
and programs of all-inclusive care for the elderly. 

[A] Cost-sharing amounts include payments for applicable vaccine 
administration fees. 

[B] Retail prices presented are those reported by vaccine 
manufacturers to CDC and do not include vaccine administration costs. 

[C] The average, median, and range of cost sharing for tetanus include 
both Td and Tdap vaccinations. 

[End of table] 

In addition to difficulty affording cost sharing, difficulty affording 
up-front payments can be a significant challenge to many 
beneficiaries. Because physicians are typically out of network for 
Part D vaccinations and do not have the real-time systems to verify 
coverage and bill Part D plans, beneficiaries may have to pay the full 
cost of their vaccination to the physician's office up front and 
obtain reimbursement from their Part D plans themselves. Our analysis 
of Part D data shows that in 2009, nearly one in five shingles 
vaccination reimbursement requests (18 percent) and more than four in 
five Td/Tdap vaccination reimbursement requests (84 percent) were 
submitted by a beneficiary, indicating that Part D beneficiaries often 
paid up front for their vaccinations and obtained reimbursement 
themselves.[Footnote 52] Beneficiaries who have to pay up front and 
obtain reimbursement from their Part D plans themselves may be less 
inclined to get vaccinated, and the up-front costs of a vaccination 
could be prohibitive for low-income Part D beneficiaries. Moreover, 
stakeholders, including Part D plan sponsors, told us that because 
Part D beneficiaries rarely submit Medicare reimbursements themselves, 
beneficiaries often encounter difficulties doing so. 

Stakeholders' Recommendations to Improve Access to Part D Vaccinations 
Include Facilitating Payment to Physicians and Increasing Pharmacists' 
Authority to Administer Vaccinations: 

Many stakeholders have raised concerns about the administrative 
challenges associated with Medicare Part D and have recommended a 
range of actions to improve beneficiaries' access to Part D-covered 
vaccinations. Stakeholder recommendations, articulated at our IOM-
facilitated discussion and conveyed in numerous correspondences and 
reports, include improving physicians' ability to verify coverage and 
bill Part D plans, consolidating Medicare coverage of vaccinations 
under Part B, and increasing pharmacists' authority to administer 
vaccinations in some states. CMS has issued some guidance on improving 
out-of-network billing for plans and providers, but participants at 
our IOM-facilitated discussion and other stakeholders report that 
administrative challenges persist and further action is needed. 
Consolidating Medicare coverage of all vaccinations under Medicare 
Part B has broad support among stakeholders, but it would require 
legislation and would likely increase federal Medicare costs. Finally, 
easing restrictions on pharmacists' authority to administer 
vaccinations could also increase access in states that currently 
impose limits, but would require state authorization. 

Improving Physicians' Ability to Verify Coverage and Bill Part D Plans 
Could Help Improve Access: 

A number of stakeholders, including those representing physicians, 
report ongoing administrative challenges associated with Part D 
vaccinations and recommend improving physicians' ability to verify 
beneficiaries' Part D coverage and bill Part D plans to help improve 
access to routinely recommended vaccinations. CMS has issued some 
guidance to Part D plans and providers on options for facilitating out-
of-network billing, such as a model vaccine notice that would provide 
plan-specific information on Part D coverage for physicians, [Footnote 
53] but participants at our IOM-facilitated discussion and other 
stakeholders report that further steps are needed. For example, one 
option identified, but not actively promoted, by CMS is to allow 
physicians to verify beneficiaries' Part D coverage and bill Part D 
plans for vaccinations in real time by using a web-based billing 
system. The American Medical Association, Part D plan sponsors, and 
others participating in our IOM-facilitated discussion have reported 
that such systems that allow physicians to submit claims to Part D 
plans could address some of the administrative challenges associated 
with Part D-covered vaccinations. However, as of July 2011, a single 
private company markets such a web-based system contracting with Part 
D plans for out-of-network reimbursements, and the system was not well 
known.[Footnote 54] 

The American Medical Association and others have reported that there 
is limited awareness among physicians of the web-based billing system, 
and that without such a system to facilitate vaccinations at the 
physician's office, patients may not get vaccinated at all. Further, 
the American Medical Association commented that efforts to increase 
awareness of the web-based billing system have been insufficient. We 
also found in our survey of physicians that nearly 3 in 4 physicians 
were not aware of any web-based billing systems that would allow them 
to electronically determine patient Part D coverage, submit claims for 
reimbursement for Part D vaccinations, or both.[Footnote 55] In 
addition, participants at our IOM-facilitated discussion noted that 
physicians may be reluctant to install an additional billing system. 
They also noted that not all Part D plans participate in the web-based 
system. According to CMS, the web-based system could improve 
physicians' ability to bill Part D plans, but agency officials 
indicated that the agency would not promote this specific system 
because it was owned by a private company. 

CMS has also provided limited guidance to Part D plans and providers 
regarding out-of-network billing options. The CMS guidance encourages 
Part D plans to offer beneficiaries vaccine-specific notices to take 
to their physician's office with instructions for the office on how to 
submit the out-of-network reimbursement for the beneficiary. CMS also 
informed physicians that they could coordinate with pharmacies to have 
them ship or deliver vaccines to physicians' offices, as well as 
coordinate with pharmacies to bill Part D plans for the vaccines. 
Beyond this guidance, a CMS official told us that the agency did not 
have plans to further facilitate physicians' ability to bill Part D 
plans and is limited in its ability to take action by the design of 
Part D. Despite these efforts, participants at our IOM-facilitated 
discussion in December 2010 noted that administrative challenges 
associated with Part D continue to hinder beneficiaries' access to 
vaccinations. In 2005, CMS acknowledged the potential for developing 
automatic crossover procedures to allow physicians to submit Part B 
claims for Part D-covered vaccinations that would be forwarded to the 
appropriate Part D plans.[Footnote 56] More recently, CMS told us that 
Part B and Part D claim standards and systems are incompatible. While 
experience with Part D implementation may have brought to light 
technical difficulties inherent in coordinating these systems, it also 
demonstrated that some physicians have been able to submit and receive 
reimbursement for Part D claims using a web-based process. It is not 
clear that CMS has fully explored options for facilitating such a 
process for all physicians who seek to administer Part D-covered 
vaccinations. 

Consolidating Vaccinations under Part B Has Broad Support but Would 
Require Legislation and Would Likely Increase Federal Costs: 

A range of stakeholders--including advisory groups; government 
agencies; and physician, pharmacy, and industry groups--have 
recommended consolidating Medicare coverage of all vaccinations under 
Medicare Part B. Stakeholders reported that consolidating vaccinations 
under Part B could address several administrative challenges 
associated with Part D--including challenges related to physicians' 
status as out-of-network providers, lack of beneficiary vaccine 
coverage, and beneficiary difficulty understanding Part D coverage. 
Many participants in our IOM-facilitated discussion--including 
officials from industry, professional organizations, and government 
agencies and researchers--recommended consolidating all vaccinations 
under Part B. As one participant noted, the complexity of the 
administrative processes associated with these vaccines creates 
challenges and adds cost. Providers do not know how much vaccine to 
stock, or how much they will be reimbursed once they deliver a 
vaccination. The more complex the process, the more staff time is 
needed to run the process. While participants cited a multitude of 
factors affecting beneficiary access to vaccinations covered under 
Part D, including difficulties storing the shingles vaccine and the 
limited supply of the vaccine, most participants identified 
administrative challenges associated with Part D as a primary concern. 
A CDC expert on shingles vaccination issues also stated that, without 
addressing this issue, the percentage of beneficiaries receiving the 
shingles vaccination would be limited. 

The recommendation to cover all vaccinations under Part B raised by 
the IOM discussion participants is consistent with recommendations 
made by other stakeholders. Over 60 professional and advocacy 
organizations--including MedPAC, the National Vaccine Advisory 
Committee, and the American Medical Association--have made similar 
recommendations. In addition, 86 percent of physicians in our survey 
and the majority of the articles in our literature review recommended 
consolidating coverage of vaccinations under Part B.[Footnote 57] 
Several provider professional organizations have proposed that the 
Secretary of Health and Human Services use existing authority to 
provide for Medicare Part B coverage for "additional preventive 
services" to include a broader range of adult vaccinations than those 
already specifically provided for in statute.[Footnote 58] Under this 
authority, the Secretary may include certain services under Part B if, 
among other things, they are recommended with a grade of A or B by the 
U.S. Preventive Services Task Force (USPSTF). HHS has determined that 
because USPSTF has not made such a recommendation in relation to 
vaccines, this authority is inapplicable.[Footnote 59] 

Consolidating Medicare coverage of all vaccinations under Medicare 
Part B has broad support among stakeholders, but it would require 
legislation and would likely increase federal Medicare costs. HHS has 
acknowledged that consolidating vaccinations under Part B could 
address some administrative challenges, but has determined that the 
department does not have the authority to do so. In 2005, before Part 
D was implemented, HHS reported that because vaccinations have 
traditionally been provided by physicians, coverage under both Part B 
and Part D raised administrative complexity issues for physicians and 
Part D.[Footnote 60] And while some stakeholders have suggested that 
CMS has administrative authority to cover routinely recommended 
vaccinations under Part B, CMS officials told us that additional 
legislation would be needed to do so. Further, the Congressional 
Budget Office (CBO) and CMS studies have reported that although 
consolidating vaccinations under Part B could decrease beneficiaries' 
cost sharing, it could also increase federal Medicare costs. In 2009, 
CBO estimated the federal cost of proposed legislation consolidating 
coverage of all vaccinations under Part B at $1.5 billion over the 10-
year period 2010-2019.[Footnote 61] According to CBO officials, this 
amount was due, in part, to an assumption that more Medicare 
beneficiaries would receive the shingles vaccine through Medicare if 
it were covered under Part B since more beneficiaries have Part B 
coverage than have Part D coverage and because it would be easier for 
physicians to provide and administer vaccinations under Part B. CBO's 
estimate also took into account the likelihood of new vaccines being 
developed and covered by Medicare. Earlier, in 2007, when MedPAC 
recommended that Part B--and not Part D--should cover routinely 
recommended vaccinations, CBO estimated that consolidating all 
vaccines under Part B would increase Medicare spending by $0 to $50 
million for 1 year and by $0 to $1 billion over 5 years.[Footnote 62] 
These findings--that the costs to Medicare could increase if all 
vaccines were covered under Part B--are consistent with a more recent 
CMS-contracted report that found that covering all vaccinations under 
Part B could decrease beneficiaries' cost sharing for vaccinations 
currently covered under Part D but would likely increase federal 
Medicare costs.[Footnote 63] 

While available estimates show increased costs to Medicare if all 
vaccinations were consolidated under Part B, two recent developments 
could affect future costs to Medicare by increasing the number of 
individuals obtaining some vaccinations prior to enrolling in 
Medicare. First, as of September 23, 2010, PPACA mandated "first-
dollar coverage" for vaccinations, requiring private insurance plans 
to cover all ACIP-recommended vaccinations with no patient cost 
sharing.[Footnote 64] This coverage may provide an incentive for 
individuals to obtain the shingles vaccination between the ages of 60--
when the vaccine is currently first recommended--and 64, if they have 
private insurance that would make the vaccine available to them at no 
cost, as opposed to waiting until age 65 or older when they are in 
Medicare and responsible for more cost sharing. Also, physicians and 
pharmacies may be more likely to stock the shingles vaccine if more 
individuals have coverage. Similarly, more beneficiaries may enter 
Medicare up-to-date on their Td/Tdap boosters because these boosters 
will also be available with first-dollar coverage under private health 
insurance plans. Second, in March 2011, the Food and Drug 
Administration approved the shingles vaccine for individuals beginning 
at age 50--10 years earlier than the currently recommended age of 60--
potentially increasing the number of individuals entering Medicare 
having already received the onetime shingles vaccination. In June 
2011, ACIP considered reducing its recommendation to age 50, but 
declined to do so, citing, among other factors, the ongoing problem 
with shingles vaccine supply. However, ACIP also indicated that it 
would reconsider its recommendation when sustained supplies of the 
shingles vaccine became more available. 

Increasing Pharmacists' Ability to Provide Vaccinations Could Improve 
Access in Several States but Would Require State Authorization: 

Pharmacy groups have recommended increasing the involvement of 
pharmacies in promoting and administering vaccinations as a way to 
improve access, but doing so would require authorization in some 
states. Pharmacy groups, such as the American Pharmacists Association 
and the National Association of Chain Drug Stores, as well as a CDC 
official and other stakeholders participating in our IOM-facilitated 
discussion, reported that pharmacies can be convenient locations for 
vaccinations given pharmacies' multiple sites in the community and the 
ease with which beneficiaries can access pharmacy services.[Footnote 
65] In addition, a pharmacy representative participating in our 
facilitated discussion noted that unlike most physicians, pharmacies 
can promote vaccinations to a large audience through posters and 
billboards and have an economic incentive to do so. 

The American Pharmacists Association, the National Association of 
Chain Drug Stores, and others have advocated for allowing all 
pharmacists to also administer shingles and Td/Tdap vaccines in all 
states. However, according to the American Pharmacists Association, 
not all states authorize pharmacists to administer all Part D-covered 
vaccines. Pharmacists are allowed to administer at least some 
vaccinations in all 51 states, but according to the American 
Pharmacists Association, as of October 2011, pharmacists in 4 states 
did not have the authority to administer shingles vaccinations and 
pharmacists in 9 states did not have the authority to administer 
Td/Tdap vaccinations. 

Conclusions: 

Determining the barriers affecting Medicare beneficiaries' access to 
recommended Part D-covered vaccines is a complex undertaking. In 
looking at the Part D-covered vaccines that are routinely recommended, 
a multitude of factors stand out, complicating any recommendation for 
how to improve access. Physicians and pharmacies do not always stock 
the vaccines, for many reasons, including cost, administrative billing 
challenges, and supply issues. Physicians do not always recommend the 
vaccinations to beneficiaries, and even when they do, beneficiaries 
may decline them. For the shingles vaccine, its relatively recent 
approval and limited supply in the years since it was approved are 
likely contributors to the relatively low coverage rate. Among the 
many contributing factors affecting beneficiary access to these Part D-
covered vaccinations, no single factor can be considered to be key. 

At the same time, it is well recognized that the complexity of the 
Medicare Part D billing processes has created administrative 
challenges for physicians, the traditional providers of vaccinations 
under Part B, and for beneficiaries, who often end up seeking 
reimbursement for Part D vaccines themselves. An administrative 
solution to physicians' challenges would be to cover vaccines under 
Part B, but this would increase Medicare program costs and would need 
to consider pharmacists' role in providing additional access to 
vaccinations. CMS has taken appropriate steps to provide guidance with 
regard to how Part D plans can facilitate physician billing, 
recognizing challenges. But stakeholders reported that awareness of 
current billing options is limited and that verifying beneficiary 
coverage and billing under Part D remains burdensome for physicians. 
As the supply of the shingles vaccine increases and as new vaccines 
are approved and recommended, facilitating beneficiary access by 
reducing physicians' barriers to billing under Part D will be more 
important. Fully exploring Medicare program options now to reduce 
these administrative burdens while minimizing costs would be 
appropriate. 

Recommendation for Executive Action: 

To help improve the ability of Medicare beneficiaries to obtain 
routinely recommended vaccinations, we recommend that the 
Administrator of CMS explore options and take appropriate steps to 
address administrative challenges, such as physicians' difficulty in 
verifying beneficiaries' coverage and billing for Part D-covered 
vaccinations. 

Agency Comments: 

We provided a draft of this report to HHS for its review and comment. 
HHS's letter and general comments are reprinted in appendix VIII. HHS 
concurred with our recommendation and noted that for 2012, CMS has 
taken steps to encourage Part D plans to offer vaccines at low or no 
cost and encourage beneficiaries to utilize the vaccination benefit. 
CMS also agreed that a multitude of factors affect beneficiaries' 
access to routinely recommended vaccinations covered by Part D, and 
indicated that the agency would continue to explore options to address 
the administrative challenges associated with the Part D program. HHS 
also provided technical comments, which we incorporated as appropriate. 

We are sending copies of this report to the Secretary of Health and 
Human Services and other interested parties. In addition, the report 
is available at no charge on GAO's website at [hyperlink, 
http://www.gao.gov]. 

If you or your staffs have any questions or need additional 
information, please contact me at (202) 512-7114 or iritanik@gao.gov. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this report. GAO staff 
members who made key contributions to this report are listed in 
appendix IX. 

Signed by: 

Katherine Iritani: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

To accomplish our objectives, we reviewed national survey data from 
the Centers for Disease Control and Prevention (CDC), analyzed 
Medicare data on beneficiaries and vaccinations reimbursed under Part 
D, and surveyed nationally representative samples of primary care 
physicians and pharmacies and all 51 State Health Insurance Assistance 
Programs (SHIP)--state agencies that provide counseling and assistance 
to Medicare beneficiaries. In addition, we conducted a facilitated 
discussion with key stakeholders. 

We also obtained information on recommended vaccinations for adult 
Medicare beneficiaries by reviewing recommendations of and 
interviewing officials from the Centers for Medicare & Medicaid 
Services (CMS), CDC and its Advisory Committee on Immunization 
Practices (ACIP), and the National Vaccine Advisory Committee. 
[Footnote 66] We also interviewed officials from (1) the Medicare 
Payment Advisory Commission, (2) the Department of Health and Human 
Services' Agency for Healthcare Research and Quality, (3) the 
Infectious Diseases Society of America, (4) the National Network for 
Immunization Information, (5) the Partnership for Prevention, (6) 
AARP,[Footnote 67] (7) Families USA, (8) the Biotechnology Industry 
Organization, (9) TransactRx, (10) the National Association of Chain 
Drug Stores, (11) the American Pharmacists Association, (12) the 
National Community Pharmacists Association, (13) the American College 
of Physicians, (14) the American Medical Association, (15) the 
American Academy of Family Physicians, (16) the American Health Care 
Association, (17) the American Association of Homes and Services for 
the Aging, (18) the American Medical Directors Association, and (19) 
six Medicare Part D plan sponsors that cover almost 40 percent of all 
Part D beneficiaries. Additionally, we reviewed relevant laws, 
regulations, and guidance on coverage of routinely recommended adult 
vaccinations under Medicare and conducted a literature review. 

We conducted this performance audit from September 2010 to December 
2011 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

Analysis of CDC National Survey Data: 

To determine the extent to which Medicare beneficiaries age 65 and 
older have received the routinely recommended vaccinations that are 
covered under Part D, we obtained data from two national health 
surveys administered by CDC's National Center for Health Statistics--
2007 data from the National Immunization Survey and 2008 and 2009 data 
from the National Health Interview Survey (NHIS).[Footnote 68] We 
obtained data on the percentage of individuals age 65 and older who 
reported ever receiving a vaccination to prevent shingles or 
vaccinations to help prevent tetanus and diphtheria (Td vaccine) in 
the prior 10 years. We also obtained this information for a number of 
subgroups, including those with and without Part D coverage. 

Analysis of Medicare Data: 

We analyzed Medicare enrollment and Part D prescription drug event 
data to determine the extent to which Part D beneficiaries--both those 
enrolled in stand-alone prescription drug plans and those enrolled in 
Medicare Advantage Part D prescription drug plans--had vaccinations 
reimbursed by Part D. We analyzed Medicare enrollment data to identify 
beneficiaries with Part D coverage. Our analyses included 
beneficiaries who were ever enrolled in Part D in 2007, 2008, or 2009 
and excluded beneficiaries under age 65 and beneficiaries enrolled in 
Part D plans with restricted enrollment--employer-sponsored plans, 
religious fraternal benefit plans, CMS demonstrations, and programs of 
all-inclusive care for the elderly. 

To determine the number of Part D beneficiaries who had vaccinations 
reimbursed by Part D, we analyzed prescription drug event data from 
2007 through 2009 to identify claims with National Drug Codes (a 
unique product identifier for human drugs assigned by the Food and 
Drug Administration) associated with Part D-covered vaccinations, 
including shingles and Td/Tdap vaccinations. We analyzed the data for 
several subgroups, including by age, sex, race, Part D plan type 
(stand-alone and Medicare Advantage Part D prescription drug plans), 
and low-income subsidy (LIS)/non-LIS status. We also analyzed the 
prescription drug event data from 2007 through 2009 to determine 
beneficiaries' cost sharing for Part D vaccinations and the method of 
reimbursement for the vaccinations. 

We also estimated the percentage of Medicare beneficiaries who were 
immunocompromised since shingles vaccinations are contraindicated for 
individuals with immunocompromising conditions. ACIP identified 
immunocompromising conditions that would contraindicate shingles 
vaccinations when it made its recommendation.[Footnote 69] We analyzed 
Medicare Hierarchical Condition Categories for 2007 and 2008 to 
identify beneficiaries with categorizations that indicated that they 
may have certain immunocompromising conditions[Footnote 70] and 
analyzed Medicare Part B fee-for-service data and Part D prescription 
drug event data to identify beneficiaries whose drug regimens 
indicated that they may have immunocompromising conditions.[Footnote 
71] 

Survey of Physicians: 

To identify factors that affect Medicare beneficiaries' access to 
routinely recommended vaccinations covered under Part D, we surveyed a 
nationally representative sample of 6,500 primary care physicians--
family and internal medicine physicians. We obtained information on 
common physician practices for the shingles and Td/Tdap vaccinations 
covered under Part D and, for comparison, the pneumococcal vaccination 
covered under Part B. 

We developed a mostly closed-ended questionnaire in which physicians 
selected from a list of possible responses, or selected responses on a 
three-point scale (i.e., classifying a factor as a major barrier, a 
minor barrier, or not a barrier). We pretested the questionnaire with 
three primary care physicians and obtained comments on the survey from 
four physician professional organizations. We revised the 
questionnaire on the basis of the pretests and comments. 

Physicians employed by a federal agency and physicians who had not 
provided primary care to Medicare beneficiaries age 65 and older since 
January 1, 2008, were not eligible to participate. We used Medicare 
national provider identifier data to select a random sample of 
physicians according to three stratifications: states, urban/rural 
geography, and physician vaccination rates. 

* States: We selected 20 states, including the District of Columbia, 
to oversample based upon state Medicare populations, regional 
diversity, and beneficiary vaccination rates for both Part B-covered 
and Part D-covered vaccinations.[Footnote 72] 

* Urban/rural geography: We stratified the sample by the area in which 
the physician practiced. 

* Physician high/medium/low vaccination rate: We stratified the sample 
by physician-level vaccination rates to ensure that the survey 
captured the experiences of physicians involved in providing 
vaccinations and those less involved in providing vaccinations. We 
classified physicians as having a high, medium, or low vaccination 
rate based upon the proportion of Medicare beneficiaries served by the 
physician who had received a Part B-covered or Part D-covered 
vaccination or a vaccination prescription from the physician.[Footnote 
73] 

We fielded the questionnaire from December 2010 through March 2011 and 
received complete responses from 1,798 eligible physicians, for an 
overall response rate of 30 percent (we determined that 560 physicians 
in our original sample were not eligible, for example, because they 
were no longer in practice or were federal employees). We analyzed 
physician responses using standard descriptive statistics. Results 
were weighted to project to the national level. All estimates were 
based on self-reported information provided by the survey respondents 
and have a margin of error of plus or minus 8 percentage points or 
less at the 95 percent confidence level, unless otherwise noted. 

We performed checks on survey responses to identify inconsistent 
answers and conducted a nonresponse bias analysis to determine whether 
any bias was introduced in the results by the absence of responses 
from some members of the sample. Based on the results of our 
nonresponse bias analysis, we adjusted our survey analysis weights to 
ensure that physicians were appropriately represented in our study. We 
additionally performed statistical testing to determine whether 
physician practice characteristics (such as practice size or the 
percentage of Medicare beneficiaries that physicians reported serving) 
influenced physicians' responses to key survey questions. 

Based on our systematic survey processes and nonresponse bias 
analysis, we determined that the questionnaire results were 
representative of primary care physicians nationally and determined 
that the data were sufficiently reliable for our purposes. 

Survey of Pharmacies: 

To identify factors that affect Medicare beneficiaries' access to 
routinely recommended vaccinations covered under Part D, we also 
surveyed a nationally representative sample of 1,500 pharmacies. As 
with our physician survey, we obtained information on common practices 
for the shingles and Td/Tdap vaccinations covered under Part D and, 
for comparison, the pneumococcal vaccination covered under Part B. 

We developed a mostly closed-ended questionnaire in which pharmacies 
selected from a list of possible responses, or selected responses on a 
three-point scale (i.e., classifying a factor as a major barrier, a 
minor barrier, or not a barrier). We pretested the questionnaire with 
five pharmacies and obtained comments on the survey from two pharmacy 
professional organizations. We revised the questionnaire on the basis 
of the pretests and comments. 

Pharmacies operated by a federal agency and pharmacies that had not 
served Medicare beneficiaries age 65 and older since January 1, 2008, 
were not eligible to participate. We used Medicare national provider 
identifier data to select a random sample of pharmacies according to 
four stratifications: states, urban/rural geography, pharmacy 
vaccination rate, and pharmacy type. 

* States: We selected 20 states, including the District of Columbia, 
to oversample based upon state Medicare populations, regional 
diversity, and beneficiary vaccination rates for both Part B-covered 
and Part D-covered vaccinations.[Footnote 74] 

* Urban/rural geography: We stratified the sample by the area in which 
the pharmacy was located. 

* Pharmacy high/low vaccination rate: We stratified the sample by 
pharmacy-level vaccination rates to ensure that the survey captured 
the experiences of pharmacies involved in providing vaccinations and 
those less involved in providing vaccinations. We classified each 
pharmacy within the sampling frame as having either a high or low 
vaccination rate based upon the proportion of Medicare beneficiaries 
served by the pharmacy who obtained a Part D-covered vaccine or 
received a vaccination from the pharmacy.[Footnote 75] 

* Pharmacy type: We stratified the sample by three categories of 
pharmacies--chain, franchise, and independent pharmacies. 

We fielded the questionnaire from December 2010 through March 2011 and 
received complete responses from 694 eligible pharmacies, for an 
overall response rate of 48 percent (we determined that 48 pharmacies 
in our original sample were not eligible, for example, because they 
were no longer in business). We analyzed pharmacy responses using 
standard descriptive statistics. Results were weighted to project to 
the national level. All estimates were based on self-reported 
information provided by the survey respondents and have a margin of 
error of plus or minus 8 percentage points or less at the 95 percent 
confidence level, unless otherwise noted. 

We performed checks on survey responses to identify inconsistent 
answers and conducted a nonresponse bias analysis to determine whether 
any bias was introduced in the results by the absence of responses 
from some members of the sample. Based on the results of our 
nonresponse bias analysis, we adjusted our survey analysis weights to 
ensure that pharmacies were appropriately represented in our study. We 
additionally performed statistical testing to determine whether 
pharmacy characteristics and practices (such as pharmacy type and 
practices for offering and recommending vaccinations) influenced 
responses to key survey questions. 

Based on our systematic survey processes and nonresponse bias 
analysis, we determined that the questionnaire results were 
representative of pharmacies nationally and determined that the data 
were sufficiently reliable for our purposes. 

Survey of SHIPs: 

We also conducted a web-based survey of SHIPs in all 51 states--we 
refer to the District of Columbia as a state throughout this report--
to obtain information on beneficiary questions and concerns related to 
the shingles and Td/Tdap vaccinations covered under Part D and, for 
comparison, the pneumococcal vaccination covered under Part B. We 
developed a mostly closed-ended questionnaire in which SHIP officials 
selected from a list of possible responses. We pretested the 
questionnaire with SHIP officials from three states--California, 
Louisiana, and Utah. We additionally obtained comments on the survey 
from Families USA, a beneficiary advocacy group that contracts with 
CMS to manage the SHIPs and serves as a liaison between CMS and the 
SHIPs. We revised the questionnaire on the basis of the pretests and 
comments. 

We fielded the questionnaire from November 2010 through March 2011 and 
received a 100 percent response rate. We analyzed SHIP responses using 
standard descriptive statistics. We relied on the data as reported by 
the SHIPs and performed checks on survey responses to identify 
inconsistent answers. We determined that these data were sufficiently 
reliable for the purposes of our report. 

Facilitated Discussion with Stakeholders: 

To examine the recommendations of government agencies, advisory 
bodies, professional organizations, and other stakeholders to improve 
beneficiaries' access to the routinely recommended vaccinations 
covered under Medicare Part D, we contracted with the National Academy 
of Sciences to have the Institute of Medicine (IOM) facilitate a 
discussion with stakeholders on vaccinations covered under Part D. We 
told institute officials the type of participants we preferred, and 
they obtained input from us, IOM members, advocacy groups, and 
individual experts in the field to select stakeholders for the 
discussion. Invitations to participate were issued by IOM. In total, 
20 experts--representing government agencies; health advisory bodies 
with involvement in vaccines; physician, pharmacy, or insurance 
professional organizations; and health care researchers--participated 
(see table 11 for a list of participants and their 
affiliations).[Footnote 76] The meeting was moderated by one of the 
participants, a physician/researcher with expertise in preventive 
services. The group was not asked to reach consensus on any issues, 
and the institute was not asked to produce or publish a report of the 
meeting. We observed the meeting and subsequently reviewed its 
transcript and documents provided by meeting participants. Participant 
comments from the meeting represent individual or organizational 
statements, not a consensus of the group as a whole, and should not be 
interpreted to represent the views of IOM or all experts in the field 
of preventive services or vaccinations. 

Table 11: IOM-Facilitated Discussion Participants: 

Name: Phyllis A. Arthur; 
Title: Senior Director, Vaccines, Immunotherapeutics and Diagnostics 
Policy; 
Organization: Biotechnology Industry Organization. 

Name: Guthrie S. Birkhead, MD, MPH; 
Title: Chair; 
Organization: National Vaccine Advisory Committee.
Title: Deputy Commissioner; 
Organization: Office of Public Health, New York State Department of 
Health. 

Name: Doug Campos-Outcalt, MD, MPA; 
Title: Liaison to the Advisory Committee on Immunization Practices; 
Organization: American Academy of Family Physicians.
Title: Associate Head, Family and Community Medicine; 
Organization: University of Arizona College of Medicine, Phoenix. 

Name: Margaret S. Coleman, Ph.D.; 
Title: Economist/Health Scientist; 
Organization: Centers for Disease Control and Prevention. 

Name: Elisabeth Daniel; 
Title: Senior Associate; 
Organization: Avalere Health. 

Name: Claire Hannan, MPH; 
Title: Executive Director; 
Organization: Association of Immunization Managers. 

Name: Rafael Harpaz, MD, MPH; 
Title: Captain, U.S. Public Health Service; 
Organization: Centers for Disease Control and Prevention. 

Name: Laura Hurley, MD, MPH; 
Title: General Internist and Researcher; 
Organization: Private practice. 

Name: Scott Jauch; 
Title: Senior Manager; 
Organization: Avalere Health. 

Name: Robert S. Lawrence, MD (Moderator); 
Title: Professor of Environmental Health Sciences, Health Policy, and 
International Health; 
Organization: Center for a Livable Future Professor Johns Hopkins 
Bloomberg School of Public Health. 

Name: Martin G. Myers, MD; 
Title: Executive Director; 
Organization: National Network for Immunization Information. 

Name: Margaret Nowak; 
Title: Director; 
Organization: Avalere Health. 

Name: Edmund J. Pezalla, MD, MPH; 
Title: National Medical Director for Pharmacy Policy and Strategy; 
Organization: Aetna Pharmacy Management.
Title: Member; 
Organization: Pharmaceutical Care Management Association. 

Name: Leigh Purvis; 
Title: Senior Strategic Policy Advisor; 
Organization: AARP. 

Name: Mitchel C. Rothholz, RPh, MBA; 
Title: Chief of Staff; 
Organization: American Pharmacists Association. 

Name: William Schaffner, MD; 
Title: Professor and Chair; 
Organization: Department of Preventive Medicine Vanderbilt University 
School of Medicine.
Title: President; 
Organization: National Foundation for Infectious Diseases.
Title: Member; 
Organization: Advisory Committee on Immunization Practices.
Title: Member; 
Organization: American College of Physicians. 

Name: Elise Smith; 
Title: Vice President, Finance Policy; 
Organization: American Health Care Association. 

Name: Alexandra Stewart, J.D.; 
Title: Assistant Professor; 
Organization: Department of Health Policy, George Washington 
University School of Public Health and Health Services. 

Name: L.J. Tan, M.S., Ph.D.; 
Title: Liaison to the Advisory Committee on Immunization Practices and 
Director, Medicine and Public Health; 
Organization: American Medical Association. 

Name: Cynthia G. Tudor, Ph.D.; 
Title: Director, Medicare Drug Benefit and Medicare Parts C & D Data 
Group; 
Organization: Centers for Medicare & Medicaid Services. 

Source: GAO. 

[End of table] 

Literature Review: 

We also conducted a literature review of articles from peer-reviewed 
journals, as well as letters and reports, including those provided by 
advisory bodies and professional organizations, to identify 
stakeholder findings and recommendations. This review resulted in 65 
items that we determined to be relevant to our objectives. To conduct 
this review, we searched 16 reference databases for articles published 
from January 1, 2005, through August 10, 2010, using a combination of 
search terms, such as "Medicare" and "vaccination." In addition to 
searching the databases, we identified other potentially relevant 
research through our background research, interviews, and other audit 
work. 

[End of section[ 

Appendix II: Shingles Risk, Prevalence, and Vaccine Supply: 

Shingles Risk and Prevalence: 

Shingles, also called herpes zoster, is a viral infection that 
produces a painful, blistering rash with few treatment options. The 
rash results from a reactivation of the virus that causes chicken pox 
(varicella). In more than 1 in 10 cases, shingles may also cause 
persistent, debilitating pain at the site of the rash that can last 
for months or years after the blisters have healed, a condition known 
as postherpetic neuralgia. In addition, at least 1 in 10 individuals 
who get shingles have a rash that involves an eye, which can result in 
facial scarring and loss of vision. Finally, by one estimate, about 3 
percent of those with shingles will be hospitalized, though deaths are 
uncommon. Few treatment options exist for shingles. Prompt treatment--
within 72 hours--with oral antiviral drugs can decrease the severity 
and duration of shingles with varying degrees of success, though not 
all patients recognize the symptoms in time to start prompt treatment. 

Since almost all Americans have had chicken pox, almost all--over 98 
percent--are at risk for shingles, with older adults being more at 
risk for both shingles and postherpetic neuralgia. Based on available 
data, CDC estimates that 1 in 3 Americans--and half of those who live 
to 85-
-will develop shingles in their lifetime, with about 1 million 
episodes of shingles in the United States each year.[Footnote 77] The 
most important risk factor for the development of both shingles and 
postherpetic neuralgia is age, with much of the increased risk 
beginning at age 50. According to CDC, effectively evaluating the 
risks for recurrent shingles (a second or subsequent episode) in 
immunocompetent persons requires large populations, long-term follow-
up, adequate duration, and laboratory confirmation. Although data are 
limited, certain studies suggest a recurrence rate that is comparable 
to the rate of initial episodes. 

Shingles Vaccine (Zostavax): 

A vaccine for shingles--called Zostavax--was licensed by the Food and 
Drug Administration in 2006.[Footnote 78] In clinical trials, the 
vaccine reduced the risk of shingles in adults age 60 and older by 
about half and reduced the incidence of postherpetic neuralgia by 
about two-thirds. The vaccine has not been determined effective to 
treat shingles or postherpetic neuralgia. 

A single dose of shingles vaccine is recommended for most adults age 
60 and older. A person with certain immunocompromising conditions 
(such as the human immunodeficiency virus) or a person with severe 
immune deficiencies caused by medical conditions or medications (such 
as chemotherapy in cancer patients) should not get the shingles 
vaccine. Using Medicare data, we estimated that from 2 to 6 percent of 
Medicare beneficiaries had at least one immunocompromising condition 
that could contraindicate the shingles vaccine. 

The shingles vaccine is the only adult vaccine that must be stored 
frozen. To maintain a frozen supply of the vaccine, physicians and 
pharmacies that dispense the vaccine must have a freezer that has a 
separate sealed freezer door and reliably maintains an average 
temperature of -15 degrees Celsius (+5 degrees Fahrenheit) or colder. 
The vaccine must be administered within 30 minutes of removal from the 
freezer. The shingles vaccine manufacturer also has a refrigerated 
version that is not currently marketed in the United States. According 
to company officials, the refrigerated formulation is not currently 
marketed because it requires significantly more bulk varicella zoster 
virus than the frozen one. 

Limited Supply of Shingles Vaccine Reported by Physicians and 
Pharmacies: 

Since entering the U.S. market in 2006, the shingles vaccine has been 
subject to supply limitations necessitating back orders. According to 
the sole manufacturer, the company has periodically experienced 
difficulty meeting demand for the relatively new product. The company 
produced 6 million doses of the vaccine as of 2009. (See table 12.) A 
representative from the manufacturer reported that while the company 
has typically produced about 2 million doses each year, the company 
anticipates producing 3.2 million doses in 2011. 

Table 12: Doses of Shingles Vaccine Produced, 2006 through 2011: 

Doses (in millions); 
2006: 0.3; 
2007: 1.7; 
2008: 2.1; 
2009: 1.9; 
2010: 1.7; 
2011[A]: 3.2. 

Source: Merck & Co., Inc. data and statements. 

[A] Merck projection. 

[End of table] 

In our national surveys of physicians and pharmacies, those that stock 
the shingles vaccine frequently cited troubles stocking the vaccine 
due to shortages or order backlogs, suggesting that providers are 
experiencing difficulty maintaining a supply of the vaccine. We 
estimate that nearly 8 in 10 physicians who stock the vaccine cited 
the shortage as a barrier--47 percent cited it as a major barrier and 
29 percent as a minor barrier. More than 8 in 10 pharmacies that stock 
the vaccine cited the shortage as a barrier--56 percent cited it as a 
major barrier and 28 percent as a minor barrier. 

Representatives from the manufacturer have cited two main reasons for 
the limited supply of the shingles vaccine. The first reason is that a 
key shingles vaccine ingredient was diverted to produce a different 
vaccine. The shingles vaccine shares a key ingredient (bulk varicella 
zoster virus) with the vaccine that protects against chicken pox, and 
in 2006 CDC's ACIP revised its recommendation for the chicken pox 
vaccine, increasing the recommendation from one dose to two. Company 
officials report that in response they assigned a higher priority to 
the production of chicken pox vaccine, which limited production of the 
shingles vaccine. The second reason cited by company officials was 
delays in manufacturing the vaccine caused by complexities and 
difficulties producing the vaccine. However, in June 2011 company 
officials stated that production of the vaccine would increase. 

[End of section] 

Appendix III: Centers for Disease Control and Prevention National 
Survey and Medicare Part D Data for Selected Demographics: 

This appendix includes information from CDC on the percentage of 
adults age 65 and older reporting ever receiving a shingles 
vaccination or receiving a Td vaccination in the previous 10 years by 
selected demographic groups as of 2009 (see table 13); for 2007 
through 2009 (see table 14); and by insurance coverage (see table 15). 
This appendix also includes additional Part D data on vaccinations 
reimbursed by Part D for selected demographic groups from 2007 through 
2009 (see table 16). 

Table 13: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving a Shingles Vaccination or Receiving a Td Vaccination in 
Previous 10 Years, 2009: 

Demographic: Total; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 11.0 (10.0, 12.0); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
52.8 (51.0, 54.5). 

Demographic: Age; 65-74; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 11.6 (10.1, 13.3); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
58.3 (56.0, 60.6). 

Demographic: Age; 75-84; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 10.8 (9.2, 12.7); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
46.7 (43.8, 49.5). 

Demographic: Age; 85+; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 8.8 (6.7, 11.4); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
44.1 (39.1, 49.2). 

Demographic: Sex; Female; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 11.7 (10.4, 13.1); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
47.8 (45.5, 50.1). 

Demographic: Sex; Male; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 10.1 (8.6, 11.9); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
59.2 (56.6, 61.8). 

Demographic: Race; Non-Hispanic White only; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 12.4 (11.1, 13.7); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
54.9 (52.9, 56.9). 

Demographic: Race; Non-Hispanic Black only; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 4.7 (2.7, 7.9); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
41.6 (36.1, 47.2). 

Demographic: Race; Hispanic; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 3.8 (2.4, 6.1); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
46.5 (41.6, 51.5). 

Demographic: Race; Non-Hispanic Asian only; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 10.4 (7.2, 14.9); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
38.2 (31.2, 45.7). 

Demographic: Race; Non-Hispanic Other; 
Percentage receiving a shingles vaccination (lower bound, upper 
bound): 7.3 (3.0, 17.0); 
Percentage receiving a Td vaccination[A] (lower bound, upper bound): 
71.0 (54.0, 83.6). 

Source: CDC National Health Interview Survey. 

Notes: The 65 and older population surveyed closely corresponds to the 
Medicare population. Lower and upper bounds display 95 percent 
confidence levels for estimates. 

[A] Data include Td vaccinations administered as a treatment or as a 
preventive measure. 

[End of table] 

Table 14: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving Shingles Vaccination or Receiving Td Vaccination in the 
Previous 10 Years, 2007 through 2009: 

Vaccination: Shingles[A]; 
2007 (lower bound, upper bound): 2.3 (1.5, 3.5); 
2008 (lower bound, upper bound): 7.6 (6.6, 8.6); 
2009 (lower bound, upper bound): 11.0 (10.0, 12.0). 

Vaccination: Td[B]; 
2007 (lower bound, upper bound): 44.1 (40.7, 47.6); 
2008 (lower bound, upper bound): 51.9 (50.0, 53.8); 
2009 (lower bound, upper bound): 52.8 (51.0, 54.6). 

Source: CDC National Health Interview Survey (2008 and 2009) and 
National Immunization Survey (2007). 

Notes: The age 65 and older population surveyed closely corresponds to 
the Medicare population. Lower and upper bounds display 95 percent 
confidence levels for estimates. 

[A] National estimates of the percentage of adults age 65 and older 
who reported ever receiving a shingles vaccination. 

[B] National estimates of the percentage of adults age 65 and older 
who reported receiving a Td vaccination in the previous 10 years. Data 
include Td vaccinations administered as a treatment or as a preventive 
measure. 

[End of table] 

Table 15: Percentage of Adults Age 65 and Older Reporting Ever 
Receiving Shingles Vaccination or Receiving Td Vaccination in the 
Previous 10 Years, by Insurance Coverage, 2009: 

Vaccination: Shingles[B]; 
All respondents (lower bound, upper bound): 11.0 (10.0, 12.0); 
Without Part D coverage:
No other coverage[A](lower bound), upper bound): 10.7 (9.5, 12.1); 
With private or other coverage[A](lower bound), upper bound): 13.4 
(11.4, 15.8); 
With Part D coverage: 
No other coverage (lower bound, upper bound): 11.5 (10.0, 13.2); 
With private or other coverage[A](lower bound), upper bound): 14.6 
(12.0, 17.7). 

Vaccination: Td[C]; 
All respondents (lower bound, upper bound): 52.8 (51.0, 54.5); 
Without Part D coverage: 
No other coverage[A](lower bound), upper bound): 52.8 (50.6, 55.0); 
With private or other coverage[A](lower bound), upper bound): 54.8 
(51.8, 57.8); 
[Empty]; 
With Part D coverage: 
No other coverage (lower bound, upper bound): 52.6 (49.6, 55.5); 
With private or other coverage[A](lower bound), upper bound): 56.0 
(51.5, 60.3). 

Source: CDC National Health Interview Survey. 

Notes: The age 65 and older population surveyed closely corresponds to 
the Medicare population. Lower and upper bounds display 95 percent 
confidence levels for estimates. 

[A] Other coverage includes Medicaid, a state-sponsored or other 
government-sponsored health plan, or a military plan. 

[B] National estimates of the percentage of adults age 65 and older 
who reported ever receiving a shingles vaccination. 

[C] National estimates of the percentage of adults age 65 and older 
who reported receiving a Td vaccination in the previous 10 years. Data 
include Td vaccinations administered as a treatment or as a preventive 
measure. 

[End of table] 

Table 16: Vaccinations Reimbursed by Part D for Individuals Age 65 and 
Older by Demographic Group, 2007 through 2009: 

Demographic: Total; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 4.59; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.49. 

Demographic: Plan type; 
Medicare Advantage prescription drug plans; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 5.33; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 1.44. 

Demographic: Plan type; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 4.27; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.09. 

Demographic: LIS status; Non-LIS; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 5.93; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.63. 

Demographic: LIS status; LIS; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 1.87; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.21. 

Demographic: Age; 65-74; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 5.46; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.57. 

Demographic: Age; 75-84; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: D4.36; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.46. 

Demographic: Age; 85+; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 1.85; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.29. 

Demographic: Sex; Female; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 4.83; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.46. 

Demographic: Sex; Male; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 4.19; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.54. 

Demographic: Race; White; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 5.06; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.51. 

Demographic: Race; Black; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 0.74; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.18. 

Demographic: Race; Hispanic; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 1.26; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.43. 

Demographic: Race; Asian; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 7.42; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 0.71. 

Demographic: Race; Other[A]; 
Percentage of Part D beneficiaries reimbursed for shingles 
vaccinations: 4.32; 
Percentage of Part D beneficiaries reimbursed for Td/Tdap 
vaccinations: 1.08. 

Source: GAO analysis of 2007 through 2009 Medicare Part D data. 

Note: This table shows Part D data for beneficiaries age 65 and older 
ever enrolled in a Part D plan from 2007 through 2009, excluding those 
enrolled in employer plans, religious fraternal benefit plans, CMS 
demonstrations, and programs of all-inclusive care for the elderly. 

[A] Includes American Indians. 

[End of table] 

[End of section] 

Appendix IV: Selected Results of the GAO 2010 Physician Survey: 

This appendix summarizes the results from questions we asked primary 
care physicians on common practices for the Part D-covered shingles 
and Td/Tdap vaccines and, for comparison, the Part B-covered 
pneumococcal vaccine. We conducted a national mail and telephone 
survey of 6,500 primary care--family and internal medicine--physicians 
and weighted the responses to provide nationally representative 
estimates. 

The following tables show selected survey information on the frequency 
of physician vaccination recommendations (table 17); frequency of 
beneficiary declinations (table 18); reasons for beneficiary 
declinations (table 19); stocking practices (table 20); barriers to 
stocking, administering, or recommending the shingles, Td/Tdap, and 
pneumococcal vaccines (tables 21 through 29); awareness and use of web-
assisted billing systems (table 30); and recommendations to make it 
easier for physicians to stock and administer all routinely 
recommended vaccines (table 31). 

Table 17: Frequency of Physician Vaccination Recommendations: 

Always recommend the vaccination; 
Shingles percentage (lower bound, upper bound): 33 (29, 37); 
Td/Tdap percentage (lower bound, upper bound): 46 (40, 52); 
Pneumococcal percentage (lower bound, upper bound): 78 (74, 81). 

Usually recommend the vaccination; 
Shingles percentage (lower bound, upper bound): 35 (29, 40); 
Td/Tdap percentage (lower bound, upper bound): 28 (24, 33); 
Pneumococcal percentage (lower bound, upper bound): 19 (16, 22). 

Recommend the vaccination about half the time; 
Shingles percentage (lower bound, upper bound): 12 (9, 14); 
Td/Tdap percentage (lower bound, upper bound): 9 (5, 12); 
Pneumococcal percentage (lower bound, upper bound): 2 (1, 4). 

Occasionally recommend the vaccination; 
Shingles percentage (lower bound, upper bound): 19 (15, 22); 
Td/Tdap percentage (lower bound, upper bound): 16 (13, 19); 
Pneumococcal percentage (lower bound, upper bound): 1 (0, 2). 

Never recommend the vaccination; 
Shingles percentage (lower bound, upper bound): 2 (1, 3); 
Td/Tdap percentage (lower bound, upper bound): 1 (1,2); 
Pneumococcal percentage (lower bound, upper bound): 0 (0, 0). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

Percentages may not total to 100 percent due to rounding. 

[End of table] 

Table 18: Frequency of Beneficiary Declinations after Physicians Have 
Recommended the Vaccinations: 

Never decline the vaccination; 
Shingles percentage (lower bound, upper bound): 1 (0, 2); 
Td/Tdap percentage (lower bound, upper bound): 9 (6, 12); 
Pneumococcal percentage (lower bound, upper bound): 11 (8, 14). 

Occasionally decline the vaccination; 
Shingles percentage (lower bound, upper bound): 31 (28, 34); 
Td/Tdap percentage (lower bound, upper bound): 55 (49, 60); 
Pneumococcal percentage (lower bound, upper bound): 78 (74, 82). 

Decline the vaccination about half the time; 
Shingles percentage (lower bound, upper bound): 35 (31, 38); 
Td/Tdap percentage (lower bound, upper bound): 17 (13, 20); 
Pneumococcal percentage (lower bound, upper bound): 9 (5, 12). 

Usually decline the vaccination; 
Shingles percentage (lower bound, upper bound): 25 (21, 29); 
Td/Tdap percentage (lower bound, upper bound): 14 (11, 18); 
Pneumococcal percentage (lower bound, upper bound): 1 (1, 2). 

Always decline the vaccination; 
Shingles percentage (lower bound, upper bound): 2 (0, 4); 
Td/Tdap percentage (lower bound, upper bound): 2 (0, 3); 
Pneumococcal percentage (lower bound, upper bound): 0 (0, 0). 

Do not know; 
Shingles percentage (lower bound, upper bound): 6 (4, 8); 
Td/Tdap percentage (lower bound, upper bound): 4 (2, 6); 
Pneumococcal percentage (lower bound, upper bound): 1 (0, 1). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

Percentages may not total to 100 percent due to rounding. 

Excludes physicians who never recommend shingles, Td/Tdap, or 
pneumococcal vaccinations. 

[End of table] 

Table 19: Reasons for Beneficiary Declinations: 

Lack of Part D or other insurance coverage; 
Shingles percentage (lower bound, upper bound): 50 (45, 54); 
Td/Tdap percentage (lower bound, upper bound): 28 (24, 31); 
Pneumococcal percentage (lower bound, upper bound): N/A[A]. 

Difficulty affording cost sharing; 
Shingles percentage (lower bound, upper bound): 48 (44, 53); 
Td/Tdap percentage (lower bound, upper bound): 23 (20, 27); 
Pneumococcal percentage (lower bound, upper bound): N/A[A]. 

Concerns about safety; 
Shingles percentage (lower bound, upper bound): 26 (23, 29); 
Td/Tdap percentage (lower bound, upper bound): 29 (24, 33); 
Pneumococcal percentage (lower bound, upper bound): 37 (34, 40). 

Concerns about efficacy; 
Shingles percentage (lower bound, upper bound): 15 (12, 18); 
Td/Tdap percentage (lower bound, upper bound): 7 (5, 9); 
Pneumococcal percentage (lower bound, upper bound): 11 (8, 14). 

Need to obtain vaccination outside of physician's office; 
Shingles percentage (lower bound, upper bound): 24 (20, 27); 
Td/Tdap percentage (lower bound, upper bound): 8 (5,12); 
Pneumococcal percentage (lower bound, upper bound): 4 (2, 6). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

Excludes physicians who never recommend shingles, Td/Tdap, or 
pneumococcal vaccinations. 

[A] Nearly all Medicare beneficiaries have Part B coverage for 
pneumococcal vaccinations, which covers the vaccination with no 
beneficiary cost sharing. 

[End of table] 

Table 20: Physician Stocking Practices: 

Stock the vaccine and it is administered in my office; 
Shingles percentage (lower bound, upper bound): 31 (26, 36); 
Td/Tdap percentage (lower bound, upper bound): 83 (79, 87); 
Pneumococcal percentage (lower bound, upper bound): 91 (89, 94). 

Refer beneficiaries to a pharmacy to purchase the vaccine, and it is 
administered in my office; 
Shingles percentage (lower bound, upper bound): 26 (22, 31); 
Td/Tdap percentage (lower bound, upper bound): 4 (1, 7); 
Pneumococcal percentage (lower bound, upper bound): 1 (0, 1). 

Refer beneficiaries to a pharmacy to purchase the vaccine, and it is 
administered at the pharmacy; 
Shingles percentage (lower bound, upper bound): 28 (22, 34); 
Td/Tdap percentage (lower bound, upper bound): 3 (1, 6); 
Pneumococcal percentage (lower bound, upper bound): 3 (1, 5). 

Refer beneficiaries to the Public Health Department, and the vaccine 
is obtained and administered at the Public Health Department; 
Shingles percentage (lower bound, upper bound): 7 (4, 10); 
Td/Tdap percentage (lower bound, upper bound): 7 (4, 9); 
Pneumococcal percentage (lower bound, upper bound): 3 (2, 5). 

Refer beneficiaries to another clinic or practice, and the vaccine is 
obtained and administered there; 
Shingles percentage (lower bound, upper bound): 5 (3, 7); 
Td/Tdap percentage (lower bound, upper bound): 2 (0, 4); 
Pneumococcal percentage (lower bound, upper bound): 2 (0, 3). 

Other; 
Shingles percentage (lower bound, upper bound): 3 (1, 5); 
Td/Tdap percentage (lower bound, upper bound): 1 (1, 1); 
Pneumococcal percentage (lower bound, upper bound): 0 (0, 0). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

[End of table] 

Table 21: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by All Physicians: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 86 (82, 90); 
Major barrier percentage (lower bound, upper bound): 66 (62, 71); 
Minor barrier percentage (lower bound, upper bound): 19 (14, 24). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 87 (84, 90); 
Major barrier percentage (lower bound, upper bound): 66 (62, 69); 
Minor barrier percentage (lower bound, upper bound): 21 (18, 25). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 93 (90, 95); 
Major barrier percentage (lower bound, upper bound): 76 (72, 80); 
Minor barrier percentage (lower bound, upper bound): 17 (13, 20). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 84 (80, 88); 
Major barrier percentage (lower bound, upper bound): 62 (57, 67); 
Minor barrier percentage (lower bound, upper bound): 22 (18, 25). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 62 (58, 66); 
Major barrier percentage (lower bound, upper bound): 35 (31, 39); 
Minor barrier percentage (lower bound, upper bound): 27 (24, 30). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 35 (31, 39); 
Major barrier percentage (lower bound, upper bound): 17 (15, 20); 
Minor barrier percentage (lower bound, upper bound): 18 (14, 21). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 15 (11, 19); 
Major barrier percentage (lower bound, upper bound): 2 (1, 3); 
Minor barrier percentage (lower bound, upper bound): 13 (9, 16). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 29 (24, 35); 
Major barrier percentage (lower bound, upper bound): 8 (5, 11); 
Minor barrier percentage (lower bound, upper bound): 21 (17, 25). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 53 (48, 58); 
Major barrier percentage (lower bound, upper bound): 17 (13, 20); 
Minor barrier percentage (lower bound, upper bound): 36 (32, 40). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 83 (79, 87); 
Major barrier percentage (lower bound, upper bound): 61 (57, 65); 
Minor barrier percentage (lower bound, upper bound): 22 (19, 25). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 85 (80, 89); 
Major barrier percentage (lower bound, upper bound): 65 (60, 70); 
Minor barrier percentage (lower bound, upper bound): 20 (16, 24). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 49 (44, 54); 
Major barrier percentage (lower bound, upper bound): 8 (5, 11); 
Minor barrier percentage (lower bound, upper bound): 41 (36, 45). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 46 (41, 52); 
Major barrier percentage (lower bound, upper bound): 9 (5, 13); 
Minor barrier percentage (lower bound, upper bound): 37 (33, 42). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 47 (41, 52); 
Major barrier percentage (lower bound, upper bound): 22 (18, 25); 
Minor barrier percentage (lower bound, upper bound): 25 (21, 29). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 22: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by Physicians Who Stock the Vaccine: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 75 (65, 84); 
Major barrier percentage (lower bound, upper bound): 37 (28, 46); 
Minor barrier percentage (lower bound, upper bound): 38 (28, 47). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 80 (72, 88); 
Major barrier percentage (lower bound, upper bound): 55 (48, 61); 
Minor barrier percentage (lower bound, upper bound): 26 (17, 34). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 90 (82, 97); 
Major barrier percentage (lower bound, upper bound): 75 (69, 82); 
Minor barrier percentage (lower bound, upper bound): 14 (9, 19). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 77 (67, 88); 
Major barrier percentage (lower bound, upper bound): 56 (46, 65); 
Minor barrier percentage (lower bound, upper bound): 22 (14, 30). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 76 (70, 82); 
Major barrier percentage (lower bound, upper bound): 47 (39, 55); 
Minor barrier percentage (lower bound, upper bound): 29 (22, 36). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 21 (15, 28); 
Major barrier percentage (lower bound, upper bound): 4 (0, 8); 
Minor barrier percentage (lower bound, upper bound): 17 (11, 23). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 8 (5, 10); 
Major barrier percentage (lower bound, upper bound): 1 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 7 (4, 9). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 27 (16, 37); 
Major barrier percentage (lower bound, upper bound): 8 (1, 15); 
Minor barrier percentage (lower bound, upper bound): 19 (12, 25). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 41 (31, 51); 
Major barrier percentage (lower bound, upper bound): 8 (3, 12); 
Minor barrier percentage (lower bound, upper bound): 33 (25, 41). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 84 (78, 89); 
Major barrier percentage (lower bound, upper bound): 65 (59, 72); 
Minor barrier percentage (lower bound, upper bound): 18 (12, 25). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 85 (79, 91); 
Major barrier percentage (lower bound, upper bound): 64 (56, 71); 
Minor barrier percentage (lower bound, upper bound): 21 (14, 29). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 51 (43, 59); 
Major barrier percentage (lower bound, upper bound): 3 (1, 6); 
Minor barrier percentage (lower bound, upper bound): 48 (39, 57). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 46 (34, 59); 
Major barrier percentage (lower bound, upper bound): 7 (1, 13); 
Minor barrier percentage (lower bound, upper bound): 40 (30, 49). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 21 (15, 28); 
Major barrier percentage (lower bound, upper bound): 9 (4, 15); 
Minor barrier percentage (lower bound, upper bound): 12 (8, 16). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 23: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by Physicians Who Do Not Stock the Vaccine: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 90 (88, 93); 
Major barrier percentage (lower bound, upper bound): 79 (75, 83); 
Minor barrier percentage (lower bound, upper bound): 11 (7, 16). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 90 (86, 94); 
Major barrier percentage (lower bound, upper bound): 70 (66, 74); 
Minor barrier percentage (lower bound, upper bound): 20 (15, 24). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 94 (92, 96); 
Major barrier percentage (lower bound, upper bound): 76 (71, 82); 
Minor barrier percentage (lower bound, upper bound): 18 (13, 22). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 86 (84, 88); 
Major barrier percentage (lower bound, upper bound): 65 (59, 70); 
Minor barrier percentage (lower bound, upper bound): 22 (17, 26). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 56 (50, 62); 
Major barrier percentage (lower bound, upper bound): 30 (26, 34); 
Minor barrier percentage (lower bound, upper bound): 26 (21, 31). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 42 (37, 46); 
Major barrier percentage (lower bound, upper bound): 23 (20, 26); 
Minor barrier percentage (lower bound, upper bound): 18 (13, 23). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 18 (13, 24); 
Major barrier percentage (lower bound, upper bound): 3 (2, 4); 
Minor barrier percentage (lower bound, upper bound): 15 (10, 20). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 30 (25, 35); 
Major barrier percentage (lower bound, upper bound): 8 (5, 12); 
Minor barrier percentage (lower bound, upper bound): 22 (17, 26). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 58 (53, 63); 
Major barrier percentage (lower bound, upper bound): 21 (16, 26); 
Minor barrier percentage (lower bound, upper bound): 37 (32, 42). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 83 (78, 88); 
Major barrier percentage (lower bound, upper bound): 59 (53, 64); 
Minor barrier percentage (lower bound, upper bound): 24 (20, 28). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 85 (80, 90); 
Major barrier percentage (lower bound, upper bound): 66 (59, 72); 
Minor barrier percentage (lower bound, upper bound): 19 (15, 24). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 47 (41, 54); 
Major barrier percentage (lower bound, upper bound): 10 (6, 14); 
Minor barrier percentage (lower bound, upper bound): 37 (31, 43). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 46 (40, 52); 
Major barrier percentage (lower bound, upper bound): 10 (5, 15); 
Minor barrier percentage (lower bound, upper bound): 36 (31, 42). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 58 (52, 64); 
Major barrier percentage (lower bound, upper bound): 27 (23, 31); 
Minor barrier percentage (lower bound, upper bound): 31 (26, 35). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 24: Barriers to Stocking, Administering, or Recommending Td/Tdap 
Vaccines, Reported by All Physicians: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 41 (35, 46); 
Major barrier percentage (lower bound, upper bound): 16 (13, 20); 
Minor barrier percentage (lower bound, upper bound): 24 (19, 30). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 66 (61, 71); 
Major barrier percentage (lower bound, upper bound): 39 (35, 44); 
Minor barrier percentage (lower bound, upper bound): 27 (22, 32). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 69 (65, 74); 
Major barrier percentage (lower bound, upper bound): 42 (38, 46); 
Minor barrier percentage (lower bound, upper bound): 27 (23, 32). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 60 (54, 65); 
Major barrier percentage (lower bound, upper bound): 32 (27, 37); 
Minor barrier percentage (lower bound, upper bound): 28 (23, 32). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 24 (19, 28); 
Major barrier percentage (lower bound, upper bound): 2 (1, 3); 
Minor barrier percentage (lower bound, upper bound): 22 (17, 26). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 10 (7, 13); 
Major barrier percentage (lower bound, upper bound): 0 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 9 (7, 12). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 5 (3, 8); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 5 (2, 8). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 5 (3, 7); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 5 (3, 6). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 30 (25, 35); 
Major barrier percentage (lower bound, upper bound): 5 (3, 8); 
Minor barrier percentage (lower bound, upper bound): 24 (20, 29). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 54 (49, 59); 
Major barrier percentage (lower bound, upper bound): 27 (23, 31); 
Minor barrier percentage (lower bound, upper bound): 27 (22, 32). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 55 (49, 60); 
Major barrier percentage (lower bound, upper bound): 23 (19, 27); 
Minor barrier percentage (lower bound, upper bound): 32 (28, 36). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 30 (25, 35); 
Major barrier percentage (lower bound, upper bound): 2 (1, 3); 
Minor barrier percentage (lower bound, upper bound): 28 (23, 33). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 21 (17, 25); 
Major barrier percentage (lower bound, upper bound): 1 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 21 (17, 25). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 14 (9, 19); 
Major barrier percentage (lower bound, upper bound): 3 (1, 6); 
Minor barrier percentage (lower bound, upper bound): 11 (6, 16). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 25: Barriers to Stocking, Administering, or Recommending Td/Tdap 
Vaccines, Reported by Physicians Who Stock the Vaccines: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 35 (29, 40); 
Major barrier percentage (lower bound, upper bound): 10 (8, 13); 
Minor barrier percentage (lower bound, upper bound): 25 (19, 31). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 61 (56, 66); 
Major barrier percentage (lower bound, upper bound): 33 (29, 37); 
Minor barrier percentage (lower bound, upper bound): 28 (22, 33). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 65 (60, 70); 
Major barrier percentage (lower bound, upper bound): 37 (33, 40); 
Minor barrier percentage (lower bound, upper bound): 28 (24, 33). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 55 (50, 59); 
Major barrier percentage (lower bound, upper bound): 25 (21, 30); 
Minor barrier percentage (lower bound, upper bound): 29 (25, 34). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 22 (17, 26); 
Major barrier percentage (lower bound, upper bound): 1 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 21 (17, 25). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 8 (7, 10); 
Major barrier percentage (lower bound, upper bound): 0 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 8 (6, 10). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 4 (2, 5); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 4 (2, 5). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 4 (3, 6); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 4 (3, 6). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 25 (22, 28); 
Major barrier percentage (lower bound, upper bound): 4 (2, 5); 
Minor barrier percentage (lower bound, upper bound): 21 (19, 24). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 49 (44, 53); 
Major barrier percentage (lower bound, upper bound): 23 (20, 25); 
Minor barrier percentage (lower bound, upper bound): 26 (22, 31). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 52 (47, 57); 
Major barrier percentage (lower bound, upper bound): 21 (18, 24); 
Minor barrier percentage (lower bound, upper bound): 31 (27, 35). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 28 (24, 32); 
Major barrier percentage (lower bound, upper bound): 2 (1, 3); 
Minor barrier percentage (lower bound, upper bound): 26 (23, 30). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 19 (15, 22); 
Major barrier percentage (lower bound, upper bound): 0 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 18 (15, 22). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 8 (5, 12); 
Major barrier percentage (lower bound, upper bound): 1 (1, 2); 
Minor barrier percentage (lower bound, upper bound): 7 (4, 11). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 26: Barriers to Stocking, Administering, or Recommending Td/Tdap 
Vaccines, Reported by Physicians Who Do Not Stock the Vaccines: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 70 (55, 85); 
Major barrier percentage (lower bound, upper bound): 47 (32, 62); 
Minor barrier percentage (lower bound, upper bound): 23 (10, 36). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 93 (89, 98); 
Major barrier percentage (lower bound, upper bound): 72 (57, 87); 
Minor barrier percentage (lower bound, upper bound): 21 (7, 36). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 89 (82, 96); 
Major barrier percentage (lower bound, upper bound): 68 (52, 84); 
Minor barrier percentage (lower bound, upper bound): 21 (6, 36). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 87 (78, 96); 
Major barrier percentage (lower bound, upper bound): 65 (51, 79); 
Minor barrier percentage (lower bound, upper bound): 22 (7, 36). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 33 (18, 48); 
Major barrier percentage (lower bound, upper bound): 8 (3, 13); 
Minor barrier percentage (lower bound, upper bound): 25 (10, 39). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 18 (4, 31); 
Major barrier percentage (lower bound, upper bound): 2 (0, 3); 
Minor barrier percentage (lower bound, upper bound): 16 (3, 29). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 14 (1, 27); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 13 (0, 26). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 7 (4, 11); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 7 (4, 9). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 53 (36, 70); 
Major barrier percentage (lower bound, upper bound): 13 (3, 22); 
Minor barrier percentage (lower bound, upper bound): 40 (22, 59). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 79 (67, 90); 
Major barrier percentage (lower bound, upper bound): 49 (31, 66); 
Minor barrier percentage (lower bound, upper bound): 30 (14, 46). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 69 (53, 85); 
Major barrier percentage (lower bound, upper bound): 34 (19, 49); 
Minor barrier percentage (lower bound, upper bound): 35 (20, 51). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 39 (21, 56); 
Major barrier percentage (lower bound, upper bound): 2 (0, 3); 
Minor barrier percentage (lower bound, upper bound): 37 (20, 54). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 33 (16, 49); 
Major barrier percentage (lower bound, upper bound): 2 (0, 3); 
Minor barrier percentage (lower bound, upper bound): 31 (14, 47). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 42 (23, 60); 
Major barrier percentage (lower bound, upper bound): 14 (1, 27); 
Minor barrier percentage (lower bound, upper bound): 28 (11, 44). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 27: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by All Physicians: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 38 (34, 42); 
Major barrier percentage (lower bound, upper bound): 15 (12, 18); 
Minor barrier percentage (lower bound, upper bound): 23 (19, 26). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 58 (52, 64); 
Major barrier percentage (lower bound, upper bound): 29 (25, 33); 
Minor barrier percentage (lower bound, upper bound): 29 (25, 34). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 45 (39, 51); 
Major barrier percentage (lower bound, upper bound): 19 (14, 24); 
Minor barrier percentage (lower bound, upper bound): 26 (22, 31). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 26 (22, 29); 
Major barrier percentage (lower bound, upper bound): 4 (2, 6); 
Minor barrier percentage (lower bound, upper bound): 22 (18, 26). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 14 (10, 17); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 12 (9, 16). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 4 (2, 7); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 4 (1, 7). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 7 (3, 10); 
Major barrier percentage (lower bound, upper bound): 1 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 6 (3, 9). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 22 (17, 27); 
Major barrier percentage (lower bound, upper bound): 5 (3, 8); 
Minor barrier percentage (lower bound, upper bound): 17 (13, 20). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 35 (31, 39); 
Major barrier percentage (lower bound, upper bound): 3 (2, 4); 
Minor barrier percentage (lower bound, upper bound): 32 (28, 35). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 26 (23, 30); 
Major barrier percentage (lower bound, upper bound): 2 (1, 3); 
Minor barrier percentage (lower bound, upper bound): 25 (21, 28). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 8 (5, 11); 
Major barrier percentage (lower bound, upper bound): 2 (1, 3); 
Minor barrier percentage (lower bound, upper bound): 6 (3, 9). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 28: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by Physicians Who Stock the Vaccine: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 34 (29, 38); 
Major barrier percentage (lower bound, upper bound): 11 (9, 13); 
Minor barrier percentage (lower bound, upper bound): 23 (19, 26). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 55 (49, 62); 
Major barrier percentage (lower bound, upper bound): 25 (21, 28); 
Minor barrier percentage (lower bound, upper bound): 31 (26, 36). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 42 (36, 48); 
Major barrier percentage (lower bound, upper bound): 15 (10, 21); 
Minor barrier percentage (lower bound, upper bound): 27 (22, 31). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 25 (22, 29); 
Major barrier percentage (lower bound, upper bound): 3 (1, 5); 
Minor barrier percentage (lower bound, upper bound): 22 (18, 26). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 13 (10, 17); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 12 (8, 16). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 4 (1, 7); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 4 (1, 6). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 6 (2, 10); 
Major barrier percentage (lower bound, upper bound): 1 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 5 (2, 9). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 20 (15, 24); 
Major barrier percentage (lower bound, upper bound): 4 (2, 6); 
Minor barrier percentage (lower bound, upper bound): 16 (12, 19). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 34 (30, 38); 
Major barrier percentage (lower bound, upper bound): 3 (2, 4); 
Minor barrier percentage (lower bound, upper bound): 31 (27, 35). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 25 (21, 29); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 24 (20, 28). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 6 (3, 9); 
Major barrier percentage (lower bound, upper bound): 2 (1, 2); 
Minor barrier percentage (lower bound, upper bound): 4 (2, 7). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 29: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by Physicians Who Do Not Stock the 
Vaccine: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 90 (79, 100); 
Major barrier percentage (lower bound, upper bound): 67 (54, 79); 
Minor barrier percentage (lower bound, upper bound): 23 (12, 34). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 93 (87, 100); 
Major barrier percentage (lower bound, upper bound): 81 (69, 92); 
Minor barrier percentage (lower bound, upper bound): 13 (4, 22). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 77 (58, 97); 
Major barrier percentage (lower bound, upper bound): 55 (38, 72); 
Minor barrier percentage (lower bound, upper bound): 23 (11, 34). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 35 (23, 48); 
Major barrier percentage (lower bound, upper bound): 13 (5, 21); 
Minor barrier percentage (lower bound, upper bound): 22 (12, 33). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 18 (8, 27); 
Major barrier percentage (lower bound, upper bound): 4 (1, 7); 
Minor barrier percentage (lower bound, upper bound): 14 (4, 23). 

Barrier: Physician's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 9 (4, 14); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 9 (4, 14). 

Barrier: Physician's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 14 (6, 23); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 13 (4, 21). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 51 (36, 66); 
Major barrier percentage (lower bound, upper bound): 22 (15, 29); 
Minor barrier percentage (lower bound, upper bound): 29 (15, 42). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 44 (24, 64); 
Major barrier percentage (lower bound, upper bound): 2 (0, 6); 
Minor barrier percentage (lower bound, upper bound): 41 (23, 60). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 41 (22, 61); 
Major barrier percentage (lower bound, upper bound): 9 (0, 20); 
Minor barrier percentage (lower bound, upper bound): 33 (20, 45). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 35 (15, 54); 
Major barrier percentage (lower bound, upper bound): 6 (0, 12); 
Minor barrier percentage (lower bound, upper bound): 29 (10, 47). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 30: Physicians' Awareness and Use of Web-Assisted Billing 
Systems: 

Use system; 
Percentage (lower bound, upper bound): 11 (8, 15). 

Aware of system, but do not use it; 
Percentage (lower bound, upper bound): 14 (10, 17). 

Not aware of system; 
Percentage (lower bound, upper bound): 75 (70, 80). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

[End of table] 

Table 31: Physicians' Recommendations to Make It Easier for Physicians 
to Stock and Administer All Routinely Recommended Vaccines: 

Recommendation: If all the vaccines were covered under Part B; 
Percentage (lower bound, upper bound): 86 (83, 89). 

Recommendation: Increased reimbursement rates for vaccines and their 
administration; 
Percentage (lower bound, upper bound): 63 (59, 68). 

Recommendation: Decreased beneficiary cost sharing for Part D 
vaccinations; 
Percentage (lower bound, upper bound): 41 (37, 46). 

Recommendation: Consistent Part D reimbursement rates for vaccinations 
covered under Part D, regardless of Part D plan; 
Percentage (lower bound, upper bound): 38 (31, 44). 

Recommendation: Increased beneficiary education and/or awareness of 
routinely recommended vaccinations; 
Percentage (lower bound, upper bound): 34 (31, 37). 

Recommendation: If all the vaccines were covered under Part D; 
Percentage (lower bound, upper bound): 28 (24, 32). 

Source: GAO 2010 Physician Survey. 

Notes: The sampling frame for our survey included practicing family 
and internal medicine physicians in the United States who were not 
federal employees and who provided primary care to Medicare 
beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

[End of table] 

[End of section] 

Appendix V: Selected Results of the GAO 2010 Pharmacy Survey: 

This appendix summarizes the results from questions we asked 
pharmacies on common practices for the Part D-covered shingles and 
Td/Tdap vaccines and, for comparison, the Part B-covered pneumococcal 
vaccine. We conducted a national mail and telephone survey of 1,500 
pharmacies and weighted the responses to provide nationally 
representative estimates. 

The following tables show selected survey information on pharmacy 
stocking practices (table 32); barriers to stocking, administering, or 
recommending the shingles, Td/Tdap, and pneumococcal vaccines (tables 
33 through 41); and recommendations to make it easier for pharmacies 
to stock and administer all routinely recommended vaccines (table 42). 

Table 32: Pharmacy Stocking Practices: 

Stock the vaccine and administer to patients at our pharmacy; 
Shingles percentage (lower bound, upper bound): 26 (20, 31); 
Td/Tdap percentage (lower bound, upper bound): 18 (13, 24); 
Pneumococcal percentage (lower bound, upper bound): 42 (34, 50). 

Stock the vaccine, but do not administer the vaccine; 
Shingles percentage (lower bound, upper bound): 7 (4, 10); 
Td/Tdap percentage (lower bound, upper bound): 2 (1, 3); 
Pneumococcal percentage (lower bound, upper bound): 1 (1, 2). 

Stock the vaccine, and our pharmacy employs and/or contracts with 
medical professionals to administer the vaccine at our pharmacy; 
Shingles percentage (lower bound, upper bound): 2 (2, 2); 
Td/Tdap percentage (lower bound, upper bound): 1 (1, 2); 
Pneumococcal percentage (lower bound, upper bound): 3 (2, 3). 

Refer beneficiaries to the Public Health Department, and the vaccine 
is obtained and administered at the Public Health Department; 
Shingles percentage (lower bound, upper bound): 4 (0, 9); 
Td/Tdap percentage (lower bound, upper bound): 6 (3, 9); 
Pneumococcal percentage (lower bound, upper bound): 6 (1, 10). 

Refer beneficiaries to a physician clinic or practice, and the vaccine 
is obtained and administered there; 
Shingles percentage (lower bound, upper bound): 40 (34, 46); 
Td/Tdap percentage (lower bound, upper bound): 60 (54, 67); 
Pneumococcal percentage (lower bound, upper bound): 40 (35, 45). 

Refer beneficiaries to another pharmacy to obtain the vaccine; 
Shingles percentage (lower bound, upper bound): 18 (15, 21); 
Td/Tdap percentage (lower bound, upper bound): 7 (5, 8); 
Pneumococcal percentage (lower bound, upper bound): 6 (5, 7). 

Other; 
Shingles percentage (lower bound, upper bound): 3 (2, 4); 
Td/Tdap percentage (lower bound, upper bound): 6 (2, 10); 
Pneumococcal percentage (lower bound, upper bound): 3 (2, 4). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

Percentages may not total to 100 percent due to rounding. 

[End of table] 

Table 33: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by All Pharmacies: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 42 (32, 53); 
Major barrier percentage (lower bound, upper bound): 19 (11, 26); 
Minor barrier percentage (lower bound, upper bound): 23 (16, 31). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 53 (43, 64); 
Major barrier percentage (lower bound, upper bound): 21 (11, 30); 
Minor barrier percentage (lower bound, upper bound): 33 (26, 40). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 71 (68, 74); 
Major barrier percentage (lower bound, upper bound): 42 (33, 50); 
Minor barrier percentage (lower bound, upper bound): 29 (21, 37). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 51 (42, 60); 
Major barrier percentage (lower bound, upper bound): 31 (23, 40); 
Minor barrier percentage (lower bound, upper bound): 20 (15, 24). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 64 (54, 75); 
Major barrier percentage (lower bound, upper bound): 47 (35, 58); 
Minor barrier percentage (lower bound, upper bound): 17 (14, 21). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 45 (36, 54); 
Major barrier percentage (lower bound, upper bound): 35 (23, 47); 
Minor barrier percentage (lower bound, upper bound): 10 (3, 18). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 19 (11, 28); 
Major barrier percentage (lower bound, upper bound): 12 (4, 20); 
Minor barrier percentage (lower bound, upper bound): 7 (5, 9). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 10 (4, 17); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 10 (3, 16). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 11 (4, 19); 
Major barrier percentage (lower bound, upper bound): 1 (0, 3); 
Minor barrier percentage (lower bound, upper bound): 10 (3, 18). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 50 (38, 61); 
Major barrier percentage (lower bound, upper bound): 23 (11, 35); 
Minor barrier percentage (lower bound, upper bound): 27 (23, 30). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 59 (56, 62); 
Major barrier percentage (lower bound, upper bound): 28 (19, 37); 
Minor barrier percentage (lower bound, upper bound): 31 (23, 40). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 68 (64, 72); 
Major barrier percentage (lower bound, upper bound): 33 (24, 42); 
Minor barrier percentage (lower bound, upper bound): 35 (26, 43). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 33 (24, 41); 
Major barrier percentage (lower bound, upper bound): 6 (0, 15); 
Minor barrier percentage (lower bound, upper bound): 27 (15, 38). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 38 (30, 46); 
Major barrier percentage (lower bound, upper bound): 6 (0, 14); 
Minor barrier percentage (lower bound, upper bound): 32 (21, 42). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 43 (34, 52); 
Major barrier percentage (lower bound, upper bound): 24 (12, 35); 
Minor barrier percentage (lower bound, upper bound): 20 (12, 27). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 34: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by Pharmacies That Stock the Vaccine: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 34 (26, 41); 
Major barrier percentage (lower bound, upper bound): 11 (8, 15); 
Minor barrier percentage (lower bound, upper bound): 23 (13, 32). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 58 (51, 65); 
Major barrier percentage (lower bound, upper bound): 21 (11, 31); 
Minor barrier percentage (lower bound, upper bound): 37 (31, 44). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 78 (74, 81); 
Major barrier percentage (lower bound, upper bound): 38 (31, 46); 
Minor barrier percentage (lower bound, upper bound): 39 (33, 45). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 43 (35, 52); 
Major barrier percentage (lower bound, upper bound): 16 (7, 25); 
Minor barrier percentage (lower bound, upper bound): 28 (19, 36). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 84 (80, 87); 
Major barrier percentage (lower bound, upper bound): 56 (48, 65); 
Minor barrier percentage (lower bound, upper bound): 28 (21, 35). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 16 (11, 20); 
Major barrier percentage (lower bound, upper bound): 5 (2, 8); 
Minor barrier percentage (lower bound, upper bound): 11 (7, 14). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 19 (12, 26); 
Major barrier percentage (lower bound, upper bound): 7 (2, 13); 
Minor barrier percentage (lower bound, upper bound): 12 (8, 16). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 3 (1, 6); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 3 (1, 6). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 6 (3, 9); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 6 (3, 9). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 40 (31, 49); 
Major barrier percentage (lower bound, upper bound): 10 (0, 20); 
Minor barrier percentage (lower bound, upper bound): 30 (24, 35). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 60 (54, 65); 
Major barrier percentage (lower bound, upper bound): 28 (18, 38); 
Minor barrier percentage (lower bound, upper bound): 31 (24, 38). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 67 (62, 72); 
Major barrier percentage (lower bound, upper bound): 34 (26, 42); 
Minor barrier percentage (lower bound, upper bound): 33 (28, 38). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 27 (22, 33); 
Major barrier percentage (lower bound, upper bound): 2 (2, 2); 
Minor barrier percentage (lower bound, upper bound): 25 (20, 31). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 31 (25, 36); 
Major barrier percentage (lower bound, upper bound): 2 (2, 2); 
Minor barrier percentage (lower bound, upper bound): 29 (23, 34). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 27 (22, 32); 
Major barrier percentage (lower bound, upper bound): 7 (3, 11); 
Minor barrier percentage (lower bound, upper bound): 20 (16, 24). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 35: Barriers to Stocking, Administering, or Recommending the 
Shingles Vaccine, Reported by Pharmacies That Do Not Stock the Vaccine: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 49 (30, 69); 
Major barrier percentage (lower bound, upper bound): 25 (11, 39); 
Minor barrier percentage (lower bound, upper bound): 24 (12, 36). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 49 (30, 69); 
Major barrier percentage (lower bound, upper bound): 21 (6, 35); 
Minor barrier percentage (lower bound, upper bound): 29 (16, 41). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 65 (61, 70); 
Major barrier percentage (lower bound, upper bound): 45 (30, 60); 
Minor barrier percentage (lower bound, upper bound): 20 (6, 34). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 58 (44, 72); 
Major barrier percentage (lower bound, upper bound): 45 (31, 58); 
Minor barrier percentage (lower bound, upper bound): 13 (9, 17). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 47 (27, 68); 
Major barrier percentage (lower bound, upper bound): 39 (20, 58); 
Minor barrier percentage (lower bound, upper bound): 8 (5, 12). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 69 (54, 83); 
Major barrier percentage (lower bound, upper bound): 59 (39, 78); 
Minor barrier percentage (lower bound, upper bound): 10 (0, 23). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 19 (8, 31); 
Major barrier percentage (lower bound, upper bound): 16 (6, 26); 
Minor barrier percentage (lower bound, upper bound): 3 (1, 6). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 16 (4, 29); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 15 (3, 27). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 16 (3, 28); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 14 (2, 25). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 57 (38, 76); 
Major barrier percentage (lower bound, upper bound): 33 (14, 52); 
Minor barrier percentage (lower bound, upper bound): 24 (20, 28). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 59 (55, 62); 
Major barrier percentage (lower bound, upper bound): 27 (13, 42); 
Minor barrier percentage (lower bound, upper bound): 31 (16, 46). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 69 (64, 74); 
Major barrier percentage (lower bound, upper bound): 33 (18, 48); 
Minor barrier percentage (lower bound, upper bound): 37 (22, 51). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 37 (22, 53); 
Major barrier percentage (lower bound, upper bound): 10 (0, 26); 
Minor barrier percentage (lower bound, upper bound): 27 (8, 47). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 43 (29, 58); 
Major barrier percentage (lower bound, upper bound): 9 (0, 24); 
Minor barrier percentage (lower bound, upper bound): 34 (16, 52). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 56 (42, 70); 
Major barrier percentage (lower bound, upper bound): 37 (18, 56); 
Minor barrier percentage (lower bound, upper bound): 19 (6, 33). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 36: Barriers to Stocking, Administering, or Recommending the Td/ 
Tdap Vaccines, Reported by All Pharmacies: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 20 (12, 29); 
Major barrier percentage (lower bound, upper bound): 10 (2, 18); 
Minor barrier percentage (lower bound, upper bound): 10 (7, 13). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 51 (46, 57); 
Major barrier percentage (lower bound, upper bound): 21 (11, 32); 
Minor barrier percentage (lower bound, upper bound): 30 (21, 39). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 61 (54, 68); 
Major barrier percentage (lower bound, upper bound): 36 (31, 41); 
Minor barrier percentage (lower bound, upper bound): 25 (21, 30). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 53 (46, 60); 
Major barrier percentage (lower bound, upper bound): 30 (24, 37); 
Minor barrier percentage (lower bound, upper bound): 23 (20, 25). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 30 (23, 38); 
Major barrier percentage (lower bound, upper bound): 10 (1, 18); 
Minor barrier percentage (lower bound, upper bound): 21 (9, 32). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 25 (20, 31); 
Major barrier percentage (lower bound, upper bound): 12 (2, 22); 
Minor barrier percentage (lower bound, upper bound): 14 (5, 22). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 23 (15, 31); 
Major barrier percentage (lower bound, upper bound): 20 (13, 27); 
Minor barrier percentage (lower bound, upper bound): 3 (2, 5). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 7 (5, 9); 
Major barrier percentage (lower bound, upper bound): 1 (0, 3); 
Minor barrier percentage (lower bound, upper bound): 6 (5, 7). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 7 (5, 10); 
Major barrier percentage (lower bound, upper bound): 1 (0, 3); 
Minor barrier percentage (lower bound, upper bound): 6 (5, 8). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 58 (47, 70); 
Major barrier percentage (lower bound, upper bound): 31 (22, 40); 
Minor barrier percentage (lower bound, upper bound): 27 (20, 34). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 52 (46, 57); 
Major barrier percentage (lower bound, upper bound): 27 (19, 35); 
Minor barrier percentage (lower bound, upper bound): 24 (20, 28). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 58 (52, 64); 
Major barrier percentage (lower bound, upper bound): 33 (24, 42); 
Minor barrier percentage (lower bound, upper bound): 25 (20, 31). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 27 (15, 39); 
Major barrier percentage (lower bound, upper bound): 9 (0, 18); 
Minor barrier percentage (lower bound, upper bound): 18 (9, 27). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 27 (16, 38); 
Major barrier percentage (lower bound, upper bound): 8 (0, 17); 
Minor barrier percentage (lower bound, upper bound): 19 (10, 27). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 23 (14, 32); 
Major barrier percentage (lower bound, upper bound): 6 (2, 10); 
Minor barrier percentage (lower bound, upper bound): 17 (9, 26). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 37: Barriers to Stocking, Administering, or Recommending the Td/ 
Tdap Vaccines, Reported by Pharmacies That Stock the Vaccines: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 11 (7, 15); 
Major barrier percentage (lower bound, upper bound): 2 (0, 3); 
Minor barrier percentage (lower bound, upper bound): 9 (5, 13). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 46 (36, 56); 
Major barrier percentage (lower bound, upper bound): 19 (3, 35); 
Minor barrier percentage (lower bound, upper bound): 27 (19, 34). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 59 (51, 67); 
Major barrier percentage (lower bound, upper bound): 30 (16, 43); 
Minor barrier percentage (lower bound, upper bound): 29 (20, 38). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 44 (31, 56); 
Major barrier percentage (lower bound, upper bound): 19 (4, 33); 
Minor barrier percentage (lower bound, upper bound): 25 (18, 32). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 5 (3, 7); 
Major barrier percentage (lower bound, upper bound): 0 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 5 (3, 7). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 1 (0, 2); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 1 (0, 2). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 7 (3, 10); 
Major barrier percentage (lower bound, upper bound): 6 (2, 10); 
Minor barrier percentage (lower bound, upper bound): 1 (0, 2). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 1 (0, 2); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 1 (0, 2). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 2 (0, 4); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 2 (0, 4). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 43 (33, 52); 
Major barrier percentage (lower bound, upper bound): 8 (6, 11); 
Minor barrier percentage (lower bound, upper bound): 34 (24, 45). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 53 (48, 59); 
Major barrier percentage (lower bound, upper bound): 13 (8, 18); 
Minor barrier percentage (lower bound, upper bound): 41 (36, 45). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 58 (49, 67); 
Major barrier percentage (lower bound, upper bound): 24 (9, 39); 
Minor barrier percentage (lower bound, upper bound): 34 (24, 44). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 9 (6, 12); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 9 (6, 12). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 9 (6, 12); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 9 (6, 12). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 12 (7, 18); 
Major barrier percentage (lower bound, upper bound): 7 (2, 12); 
Minor barrier percentage (lower bound, upper bound): 6 (4, 7). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 38: Barriers to Stocking, Administering, or Recommending the Td/ 
Tdap Vaccines, Reported by Pharmacies That Do Not Stock the Vaccines: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 25 (12, 38); 
Major barrier percentage (lower bound, upper bound): 14 (2, 27); 
Minor barrier percentage (lower bound, upper bound): 11 (6, 15). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 54 (45, 62); 
Major barrier percentage (lower bound, upper bound): 22 (9, 36); 
Minor barrier percentage (lower bound, upper bound): 31 (18, 45). 

Barrier: Inconsistent Part D plans' coverage and reimbursement rates; 
Total percentage (lower bound, upper bound): 62 (53, 71); 
Major barrier percentage (lower bound, upper bound): 39 (32, 45); 
Minor barrier percentage (lower bound, upper bound): 24 (19, 28). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 57 (49, 66); 
Major barrier percentage (lower bound, upper bound): 36 (29, 43); 
Minor barrier percentage (lower bound, upper bound): 21 (17, 25). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 42 (33, 51); 
Major barrier percentage (lower bound, upper bound): 14 (1, 27); 
Minor barrier percentage (lower bound, upper bound): 28 (12, 44). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 37 (30, 44); 
Major barrier percentage (lower bound, upper bound): 17 (3, 31); 
Minor barrier percentage (lower bound, upper bound): 20 (7, 32). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 30 (20, 40); 
Major barrier percentage (lower bound, upper bound): 26 (16, 35); 
Minor barrier percentage (lower bound, upper bound): 5 (3, 7). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 10 (7, 13); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 9 (7, 10). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 10 (7, 13); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 8 (7, 10). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 64 (49, 79); 
Major barrier percentage (lower bound, upper bound): 40 (27, 53); 
Minor barrier percentage (lower bound, upper bound): 24 (15, 34). 

Barrier: Beneficiaries' lack of insurance coverage; 
Total percentage (lower bound, upper bound): 51 (44, 58); 
Major barrier percentage (lower bound, upper bound): 34 (23, 44); 
Minor barrier percentage (lower bound, upper bound): 17 (13, 21). 

Barrier: Beneficiaries' difficulty affording the cost sharing for the 
vaccine; 
Total percentage (lower bound, upper bound): 58 (51, 65); 
Major barrier percentage (lower bound, upper bound): 37 (27, 46); 
Minor barrier percentage (lower bound, upper bound): 21 (16, 27). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 36 (19, 53); 
Major barrier percentage (lower bound, upper bound): 13 (0, 26); 
Minor barrier percentage (lower bound, upper bound): 23 (9, 37). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 36 (20, 51); 
Major barrier percentage (lower bound, upper bound): 12 (0, 25); 
Minor barrier percentage (lower bound, upper bound): 24 (11, 36). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 28 (15, 40); 
Major barrier percentage (lower bound, upper bound): 5 (0, 11); 
Minor barrier percentage (lower bound, upper bound): 22 (10, 35). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 39: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by All Pharmacies: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 20 (12, 28); 
Major barrier percentage (lower bound, upper bound): 8 (1, 15); 
Minor barrier percentage (lower bound, upper bound): 12 (9, 14). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 46 (43, 50); 
Major barrier percentage (lower bound, upper bound): 17 (9, 26); 
Minor barrier percentage (lower bound, upper bound): 29 (21, 36). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 53 (46, 60); 
Major barrier percentage (lower bound, upper bound): 32 (24, 39); 
Minor barrier percentage (lower bound, upper bound): 21 (19, 23). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 33 (24, 42); 
Major barrier percentage (lower bound, upper bound): 8 (1, 16); 
Minor barrier percentage (lower bound, upper bound): 24 (19, 29). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 23 (16, 31); 
Major barrier percentage (lower bound, upper bound): 9 (0, 17); 
Minor barrier percentage (lower bound, upper bound): 15 (6, 24). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 18 (10, 26); 
Major barrier percentage (lower bound, upper bound): 8 (2, 15); 
Minor barrier percentage (lower bound, upper bound): 10 (7, 12). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 9 (3, 15); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 8 (2, 15). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 8 (2, 13); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 8 (2, 13). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 67 (61, 72); 
Major barrier percentage (lower bound, upper bound): 27 (18, 36); 
Minor barrier percentage (lower bound, upper bound): 40 (32, 47). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 35 (32, 39); 
Major barrier percentage (lower bound, upper bound): 5 (0, 13); 
Minor barrier percentage (lower bound, upper bound): 30 (22, 37). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 35 (32, 38); 
Major barrier percentage (lower bound, upper bound): 6 (0, 13); 
Minor barrier percentage (lower bound, upper bound): 29 (22, 36). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 24 (13, 34); 
Major barrier percentage (lower bound, upper bound): 5 (3, 7); 
Minor barrier percentage (lower bound, upper bound): 19 (9, 28). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 40: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by Pharmacies That Stock the Vaccine: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 7 (4, 9); 
Major barrier percentage (lower bound, upper bound): 1 (0, 1); 
Minor barrier percentage (lower bound, upper bound): 6 (4, 8). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 36 (29, 43); 
Major barrier percentage (lower bound, upper bound): 11 (4, 18); 
Minor barrier percentage (lower bound, upper bound): 25 (19, 30). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 37 (30, 44); 
Major barrier percentage (lower bound, upper bound): 14 (8, 21); 
Minor barrier percentage (lower bound, upper bound): 22 (19, 26). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 25 (13, 36); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 23 (12, 35). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 8 (6, 11); 
Major barrier percentage (lower bound, upper bound): 2 (0, 4); 
Minor barrier percentage (lower bound, upper bound): 6 (5, 8). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 11 (7, 15); 
Major barrier percentage (lower bound, upper bound): 3 (0, 6); 
Minor barrier percentage (lower bound, upper bound): 8 (6, 10). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 3 (1, 4); 
Major barrier percentage (lower bound, upper bound): 1 (0, 2); 
Minor barrier percentage (lower bound, upper bound): 1 (1, 2). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 2 (1, 3); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 2 (1, 3). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 55 (45, 64); 
Major barrier percentage (lower bound, upper bound): 20 (12, 28); 
Minor barrier percentage (lower bound, upper bound): 35 (24, 45). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 27 (18, 35); 
Major barrier percentage (lower bound, upper bound): 6 (0, 18); 
Minor barrier percentage (lower bound, upper bound): 21 (16, 25). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 26 (18, 35); 
Major barrier percentage (lower bound, upper bound): 6 (0, 18); 
Minor barrier percentage (lower bound, upper bound): 20 (15, 25). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 13 (10, 16); 
Major barrier percentage (lower bound, upper bound): 3 (1, 6); 
Minor barrier percentage (lower bound, upper bound): 10 (7, 12). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 41: Barriers to Stocking, Administering, or Recommending the 
Pneumococcal Vaccine, Reported by Pharmacies That Do Not Stock the 
Vaccine: 

Barrier: Cost of purchasing vaccine stock; 
Total percentage (lower bound, upper bound): 38 (20, 56); 
Major barrier percentage (lower bound, upper bound): 19 (3, 34); 
Minor barrier percentage (lower bound, upper bound): 20 (14, 25). 

Barrier: Low Medicare reimbursement for the cost and/or administration 
of the vaccine; 
Total percentage (lower bound, upper bound): 62 (53, 70); 
Major barrier percentage (lower bound, upper bound): 27 (9, 44); 
Minor barrier percentage (lower bound, upper bound): 35 (18, 52). 

Barrier: The time and effort required to assess beneficiary Medicare 
coverage for the vaccine and pursue Medicare reimbursement for 
providing and/or administering the vaccine; 
Total percentage (lower bound, upper bound): 74 (70, 79); 
Major barrier percentage (lower bound, upper bound): 56 (49, 62); 
Minor barrier percentage (lower bound, upper bound): 19 (14, 23). 

Barrier: Trouble stocking the vaccine due to shortage/order backlog; 
Total percentage (lower bound, upper bound): 44 (25, 63); 
Major barrier percentage (lower bound, upper bound): 18 (1, 35); 
Minor barrier percentage (lower bound, upper bound): 26 (14, 37). 

Barrier: Storage difficulties (the need to store the vaccine in a 
refrigerator/freezer); 
Total percentage (lower bound, upper bound): 46 (37, 56); 
Major barrier percentage (lower bound, upper bound): 18 (0, 38); 
Minor barrier percentage (lower bound, upper bound): 28 (8, 48). 

Barrier: State statutes/regulations do not allow pharmacist 
administration of the vaccine; 
Total percentage (lower bound, upper bound): 27 (14, 41); 
Major barrier percentage (lower bound, upper bound): 16 (5, 26); 
Minor barrier percentage (lower bound, upper bound): 12 (8, 16). 

Barrier: Pharmacy's concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 19 (7, 31); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 19 (7, 31). 

Barrier: Pharmacy's concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 16 (5, 28); 
Major barrier percentage (lower bound, upper bound): 0 (0, 0); 
Minor barrier percentage (lower bound, upper bound): 16 (5, 28). 

Barrier: Lack of, or uncertain, beneficiary demand for the vaccine; 
Total percentage (lower bound, upper bound): 83 (79, 87); 
Major barrier percentage (lower bound, upper bound): 37 (18, 55); 
Minor barrier percentage (lower bound, upper bound): 46 (28, 64). 

Barrier: Beneficiaries' concern about vaccine's safety; 
Total percentage (lower bound, upper bound): 48 (40, 56); 
Major barrier percentage (lower bound, upper bound): 4 (2, 7); 
Minor barrier percentage (lower bound, upper bound): 44 (35, 52). 

Barrier: Beneficiaries' concern about vaccine's efficacy; 
Total percentage (lower bound, upper bound): 48 (40, 56); 
Major barrier percentage (lower bound, upper bound): 5 (3, 8); 
Minor barrier percentage (lower bound, upper bound): 43 (33, 52). 

Barrier: The need for beneficiaries to transport the vaccine from a 
pharmacy to a physician to be administered; 
Total percentage (lower bound, upper bound): 39 (19, 59); 
Major barrier percentage (lower bound, upper bound): 7 (3, 11); 
Minor barrier percentage (lower bound, upper bound): 32 (12, 52). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

The sum of the percentages of major/minor barriers may not equal the 
total percentage due to rounding. 

[End of table] 

Table 42: Pharmacies' Recommendations to Make It Easier for Pharmacies 
to Stock and Administer All Routinely Recommended Vaccines: 

Recommendation: If all the vaccines were covered under Part B; 
Percentage (lower bound, upper bound): 30 (24, 36). 

Recommendations If all the vaccines were covered under Part D; 
Percentage (lower bound, upper bound): 69 (63, 75). 

Recommendation: Consistent Part D reimbursement rates for vaccinations 
covered under Part D, regardless of Part D plan; 
Percentage (lower bound, upper bound): 52 (44, 59). 

Recommendation: Increased beneficiary education and/or awareness of 
routinely recommended vaccinations; 
Percentage (lower bound, upper bound): 43 (36, 50). 

Recommendation: Decreased beneficiary cost sharing for Part D 
vaccinations; 
Percentage (lower bound, upper bound): 29 (24, 34). 

Recommendation: Increased reimbursement rates for vaccines and their 
administration; 
Percentage (lower bound, upper bound): 49 (41, 58). 

Source: GAO 2010 Pharmacy Survey. 

Notes: The sampling frame for our survey included pharmacies in the 
United States that were not operated by a federal agency and that 
served Medicare beneficiaries age 65 and older. 

Lower and upper bounds display 95 percent confidence levels for 
estimates. 

[End of table] 

[End of section] 

Appendix VI: State Health Insurance Assistance Program Survey Results: 

This appendix summarizes the results from questions we asked SHIPs--
state agencies that provide counseling and assistance to Medicare 
beneficiaries. We conducted a web-based survey of all 51 state SHIPs, 
including the District of Columbia, to obtain information on 
beneficiary questions and concerns related to vaccinations covered 
under Part D, specifically the shingles and Td/Tdap vaccinations. For 
comparison, we also asked about the Part B-covered pneumococcal 
vaccination. We obtained responses from all 51 SHIPs. 

The following tables show selected survey information on the number of 
SHIPs helping beneficiaries understand Medicare vaccination coverage 
(table 43); reporting beneficiary difficulties accessing shingles, Td/ 
Tdap, or pneumococcal vaccinations (tables 44 through 46); and making 
recommendations to improve beneficiaries' access to routinely 
recommended vaccinations (table 47). 

Table 43: Number of SHIPs Helping Beneficiaries Understand Medicare 
Vaccination Coverage: 

Beneficiaries' coverage issue: Whether a vaccination is covered by 
Medicare Part B or D; 
Number of SHIPs: 47. 

Beneficiaries' coverage issue: Cost-sharing amount for a Part D-
covered vaccination; 
Number of SHIPs: 38. 

Beneficiaries' coverage issue: How to obtain reimbursement for a Part 
D-covered vaccination; 
Number of SHIPs: 33. 

Beneficiaries' coverage issue: Up-front costs when beneficiaries have 
to pursue reimbursement themselves; 
Number of SHIPs: 30. 

Source: GAO 2010 SHIP Survey. 

[End of table] 

Table 44: Number of SHIPs Reporting Beneficiary Difficulties Accessing 
Shingles Vaccinations: 

Beneficiary difficulties: Do not know whether vaccination is covered 
by Medicare; 
Number of SHIPs: 36. 

Beneficiary difficulties: Concerns about having to transport the 
vaccine from a pharmacy to a physician to be administered; 
Number of SHIPs: 24. 

Beneficiary difficulties: Difficulty affording the cost sharing for 
vaccination; 
Number of SHIPs: 20. 

Beneficiary difficulties: Physician does not stock the vaccine; 
Number of SHIPs: 19. 

Beneficiary difficulties: Difficulty affording up-front costs of 
vaccination when responsible for pursuing reimbursement; 
Number of SHIPs: 18. 

Beneficiary difficulties: Pharmacy does not administer the vaccine; 
Number of SHIPs: 17. 

Beneficiary difficulties: Difficulty pursuing reimbursement for 
vaccination; 
Number of SHIPs: 14. 

Beneficiary difficulties: Pharmacy does not stock the vaccine; 
Number of SHIPs: 10. 

Beneficiary difficulties: Do not have Part D or other insurance 
coverage for vaccination; 
Number of SHIPs: 10. 

Beneficiary difficulties: Physician does not administer the vaccine; 
Number of SHIPs: 9. 

Source: GAO 2010 SHIP Survey. 

[End of table] 

Table 45: Number of SHIPs Reporting Beneficiary Difficulties Accessing 
Td/Tdap Vaccinations: 

Beneficiary difficulties: Do not know whether vaccination is covered 
by Medicare; 
Number of SHIPs: 16. 

Beneficiary difficulties: Pharmacy does not stock the vaccine; 
Number of SHIPs: 3. 

Beneficiary difficulties: Concerns about having to transport the 
vaccine from a pharmacy to a physician to be administered; 
Number of SHIPs: 3. 

Beneficiary difficulties: Do not have Part D or other insurance 
coverage for vaccination; 
Number of SHIPs: 3. 

Beneficiary difficulties: Difficulty pursuing reimbursement for 
vaccination; 
Number of SHIPs: 3. 

Beneficiary difficulties: Physician does not administer the vaccine; 
Number of SHIPs: 2. 

Beneficiary difficulties: Difficulty affording the cost sharing for 
vaccination; 
Number of SHIPs: 2. 

Beneficiary difficulties: Difficulty affording up front costs of 
vaccination when responsible for pursuing reimbursement; 
Number of SHIPs: 2. 

Beneficiary difficulties: Pharmacy does not administer the vaccine; 
Number of SHIPs: 1. 

Beneficiary difficulties: Physician does not stock the vaccine; 
Number of SHIPs: 0. 

Source: GAO 2010 SHIP Survey. 

[End of table] 

Table 46: Number of SHIPs Reporting Beneficiary Difficulties Accessing 
Pneumococcal Vaccinations: 

Beneficiary difficulties: Do not know whether vaccination is covered 
by Medicare; 
Number of SHIPs: 20. 

Beneficiary difficulties: Pharmacy does not administer the vaccine; 
Number of SHIPs: 4. 

Beneficiary difficulties: Difficulty pursuing reimbursement for 
vaccination; 
Number of SHIPs: 4. 

Beneficiary difficulties: Difficulty affording up-front costs of 
vaccination when responsible for pursuing reimbursement; 
Number of SHIPs: 3. 

Beneficiary difficulties: Physician does not stock the vaccine; 
Number of SHIPs: 2. 

Beneficiary difficulties: Physician does not administer the vaccine; 
Number of SHIPs: 2. 

Beneficiary difficulties: Pharmacy does not stock the vaccine; 
Number of SHIPs: 2. 

Beneficiary difficulties: Concerns about having to transport the 
vaccine from a pharmacy to a physician to be administered; 
Number of SHIPs: 1. 

Source: GAO 2010 SHIP Survey. 

[End of table] 

Table 47: SHIP Recommendations to Improve Beneficiaries' Access to 
Routinely Recommended Vaccinations: 

Recommendations: Increased beneficiary education and awareness of 
routinely recommended vaccinations; 
Number of SHIPs: 42. 

Recommendations: Coverage of all vaccinations under Part B; 
Number of SHIPs: 39. 

Recommendations: Consistent Part D cost sharing for vaccinations 
covered under Part D; 
Number of SHIPs: 29. 

Recommendations: Decreased beneficiary cost sharing for Part D 
vaccinations; 
Number of SHIPs: 28. 

Recommendations: Coverage of all vaccinations under Part D; 
Number of SHIPs: 12. 

Source: GAO 2010 SHIP Survey. 

[End of table] 

[End of section] 

Appendix VII: Beneficiaries' Part D Cost Sharing for Shingles and Td/ 
Tdap Vaccinations: 

This appendix presents Medicare data on the amount paid for shingles 
and Td/Tdap vaccinations by Part D beneficiaries who were not 
receiving the low-income subsidy (LIS). Beneficiary cost sharing data 
include any applicable vaccine administration costs and are presented 
for each of the three Part D coverage phases--initial, coverage gap 
(donut hole), and catastrophic.[Footnote 79] In 2009, more than 90 
percent of Part D beneficiaries who had a shingles or Td/Tdap 
vaccination reimbursed by Part D received their vaccination in the 
initial Part D coverage phase. Part D beneficiaries vaccinated during 
the initial phase paid, on average, $53 for a shingles vaccination 
(see table 48) and $25 for a Td/Tdap vaccination (see table 49). Part 
D beneficiaries vaccinated while in the donut hole generally had 
higher cost sharing, averaging $151 for a shingles vaccination and $35 
for a Td/Tdap vaccination. However, starting on January 1, 2011, a 
provision in the Patient Protection and Affordable Care Act reduced 
Part D beneficiaries' cost sharing in the donut hole by 50 percent for 
applicable drugs, including shingles and Td/Tdap vaccinations. 
[Footnote 80] 

Table 48: 2009 Cost-Sharing Amounts for Shingles Vaccinations by Phase 
for Beneficiaries Age 65 and Older with Part D Coverage (Non-LIS): 

Phase: Initial; 
Percentage of claims: 95.1; 
Average cost sharing: $53; 
Median cost sharing: $39; 
Range of cost sharing: $0-$195; 
Range of cost sharing, 10th to 90th percentile: $30-$82. 

Phase: Coverage gap; 
Percentage of claims: 4.1; 
Average cost sharing: $151; 
Median cost sharing: $170; 
Range of cost sharing: $0-$195; 
Range of cost sharing, 10th to 90th percentile: $54-$188. 

Phase: Catastrophic; 
Percentage of claims: 0.8; 
Average cost sharing: $13; 
Median cost sharing: $9; 
Range of cost sharing: $0-$190; 
Range of cost sharing, 10th to 90th percentile: $8-$11. 

Source: GAO. 

Notes: This table presents analysis of 2009 Medicare Part D data for 
Part D beneficiaries age 65 and older who were not receiving the LIS, 
excluding claims from employer plans, religious fraternal benefit 
plans, CMS demonstrations, and programs of all-inclusive care for the 
elderly. Cost-sharing amounts include applicable vaccine 
administration costs. 

[End of table] 

Table 49: 2009 Cost-Sharing Amounts for Td/Tdap Vaccinations by Phase 
for Beneficiaries Age 65 and Older with Part D Coverage (Non-LIS): 

Phase: Initial; 
Percentage of claims: 96.6; 
Average cost sharing: $25; 
Median cost sharing: $27; 
Range of cost sharing: $0-$70; 
Range of cost sharing, 10th to 90th percentile: $10-$40. 

Phase: Coverage gap; 
Percentage of claims: 2.9; 
Average cost sharing: $35; 
Median cost sharing: $27; 
Range of cost sharing: $0-$70; 
Range of cost sharing, 10th to 90th percentile: $20-$59. 

Phase: Catastrophic; 
Percentage of claims: 0.4; 
Average cost sharing: $9; 
Median cost sharing: $6; 
Range of cost sharing: $0-$59; 
Range of cost sharing, 10th to 90th percentile: $0-$37. 

Source: GAO. 

Note: This table presents analysis of 2009 Medicare Part D data for 
Part D beneficiaries age 65 and older who were not receiving the LIS, 
excluding claims from employer plans, religious fraternal benefit 
plans, CMS demonstrations, and programs of all-inclusive care for the 
elderly. Cost-sharing amounts presented include applicable vaccine 
administration costs and includes both Td and Tdap vaccinations. 

[End of table] 

Beneficiaries' average cost sharing for shingles and Td/Tdap 
vaccinations increased from 2007 through 2009, particularly for 
Td/Tdap vaccinations (see table 50). 

Table 50: Average Cost-Sharing Amounts for Shingles and Td/Tdap 
Vaccinations for Non-LIS Part D Beneficiaries Age 65 and Older, 2007 
through 2009: 

Vaccine: Shingles; 
Average cost sharing: 2007: $48; 
Average cost sharing: 2008: $54; 
Average cost sharing: 2009: $57. 

Vaccine: Td/Tdap; 
Average cost sharing: 2007: $3; 
Average cost sharing: 2008: $15; 
Average cost sharing: 2009: $25. 

Source: GAO. 

Notes: This table presents analysis of 2009 Medicare Part D data for 
Part D beneficiaries age 65 and older who were not receiving the LIS, 
excluding beneficiaries enrolled in employer plans, religious 
fraternal benefit plans, CMS demonstrations, and programs of all-
inclusive care for the elderly. 

Cost-sharing amounts for 2008 and 2009 include payments toward vaccine 
administration fees. Cost-sharing amounts for 2007 exclude payments 
toward vaccine administration fees. Prior to 2008, administration fees 
for Part D-covered vaccines were reimbursed by Part B. Td/Tdap average 
cost sharing includes both Td and Tdap vaccinations. 

[End of table] 

[End of section] 

Appendix VIII: Comments from the Department of Health and Human 
Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

November 18, 2011: 

Katherine Iritani: 
Director, HealthCare: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Ms. Iritani: 

Attached ate comments on the U.S. Government Accountability Office's 
(GAO) draft report entitled, "Medicare: Many Factors, Including 
Administrative Challenges, Affect Access to Part D Vaccinations" (GAO-
12-61). 

The Department appreciates the opportunity to review this report 
before its publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled, 
"Medicare: Many Factors, Including Administrative Challenges, Affect 
Access To Part D Vaccinations" (GAO-12-61): 

Thank you for the opportunity to review and comment on this draft 
report. As the report notes, vaccines have the potential to prevent 
disease and improve the quality of life for individuals enrolled in 
Medicare, in addition to improving public health in the United States 
overall. To this end, the Centers for Medicare and Medicaid Services 
(CMS) has taken steps to improve access to vaccines covered by Part D. 
All Part D formularies are reviewed to ensure inclusion of licensed 
vaccines. In addition, for Contract Year 2012, CMS has announced a 
simplified six tier formulary design that allows Part D plans to have 
a 6th tier in its benefit design if it is a tier that provides a 
meaningful benefit offering, such as a $0 vaccine-only tier. The 
purpose of this policy is to encourage Part D sponsors to offer 
vaccines at low or no cost and encourage beneficiaries to utilize the 
vaccination benefit. 

GAO Recommendation: 

To help improve the ability of Medicare beneficiaries to obtain 
routinely recommended vaccinations, GAO recommend that the 
Administrator of CMS explore options and take appropriate steps to 
address administrative challenges, such as physicians' difficulty in 
verifying beneficiaries' coverage and billing for Part D-covered 
vaccinations. 

CMS Response: 

We concur with the recommendation for CMS to explore options and take 
appropriate steps to improve access to Part D covered vaccinations. We 
agree that a multitude of factors affect beneficiaries' access to 
routinely recommended Part D-covered vaccinations, particularly the 
low percentage of physicians and pharmacies that stock the relatively 
new shingles vaccine. We also agree that a number of stakeholders are 
involved in ensuring that Medicare beneficiaries have access to 
routinely recommended vaccinations. As to the administrative 
challenges associated with the Medicare Part D program in particular, 
we continue to explore options to increase beneficiary access to 
vaccines covered by the Part Don top of the guidance that we have 
already issued which is referenced in the proposed report. 

[End of section] 

Appendix IX: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Katherine Iritani, (202) 512-7114 or iritanik@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Kim Yamane, Assistant 
Director; George Bogart; Michael Erhardt; Roseanne Price; Terry Saiki; 
Eden Savino; and Jessica Smith made major contributions to this report. 

[End of section] 

Footnotes: 

[1] Medicare also provides coverage to certain individuals with 
disabilities as well as individuals with end-stage renal disease. 

[2] Medicare began Part B coverage for vaccinations to prevent 
pneumonia (pneumococcal vaccine) in 1980 and began coverage for 
vaccinations to protect against influenza in 1993. In addition, Part B 
covers vaccinations against hepatitis B for certain individuals and 
vaccinations incident to the treatment of an injury or incidence of 
exposure--for example, vaccinations to treat potential exposure to 
tetanus as the result of an injury, such as after a patient stepped on 
a rusty nail that may have exposed him or her to the disease. 

[3] In this report, we use the term routinely recommended vaccinations 
to indicate adult vaccinations that are recommended by the Centers for 
Disease Control and Prevention and its Advisory Committee on 
Immunization Practices (ACIP) for most people within an age group. For 
more information on ACIP vaccination recommendations, see [hyperlink, 
http://www.cdc.gov/vaccines/recs/acip/] (accessed Sept. 29, 2011). 

[4] Shingles, also called herpes zoster, results from a reactivation 
of the virus that causes chicken pox. The risk of developing shingles 
increases after age 50. 

[5] Tetanus is a serious disease (also known as lockjaw) that causes 
painful tightening of the muscles and leads to death in about 1 in 10 
cases; diphtheria is a disease that can lead to breathing problems, 
paralysis, heart failure, and potentially death; and pertussis is the 
disease commonly known as whooping cough. Both the Td and Tdap 
vaccinations protect against tetanus and diphtheria, and the Tdap 
vaccination protects against pertussis as well. After the initial 
vaccinations, Td vaccination is recommended as a booster every 10 
years and Tdap as a onetime replacement for a Td booster. Unless 
otherwise indicated, references to the Td/Tdap vaccinations in this 
report refer to vaccinations administered as a preventive measure and 
not in response to exposure. 

[6] Postherpetic neuralgia is a persistent, debilitating pain at the 
site of the shingles rash that can last for months or years after the 
blisters have healed. 

[7] Plans may differ in the drugs they cover within specific 
therapeutic categories, but all Part D plans must cover all licensed 
vaccines not available under Part B, when used for a medically 
accepted indication. 

[8] Pub. L. No. 111-148, § 4204(e), 124 Stat. 119, 572 (2010). 

[9] This report focuses on Medicare beneficiaries age 65 and older. In 
2009, over 97 percent of individuals age 65 and older were enrolled in 
Medicare. Nearly all Americans age 65 and older are automatically 
enrolled in Medicare Part A, and in this report, the term Medicare 
beneficiaries refers to those age 65 and older in Medicare Part A. 
Part A provides hospital insurance that helps cover inpatient care in 
hospitals and hospices, related posthospital care in skilled nursing 
facilities, and home health services. When we refer to those 
beneficiaries age 65 and older enrolled in Medicare Part D, we call 
them Part D beneficiaries. About 58 percent of Part A beneficiaries 
are also enrolled in a Part D outpatient prescription drug plan. 

[10] The National Vaccine Advisory Committee makes recommendations to 
the Director of HHS's National Vaccine Program, which is responsible 
for coordinating and ensuring collaboration among federal agencies 
involved in vaccination and immunization activities. 

[11] The National Immunization Survey is conducted jointly by CDC's 
National Center for Health Statistics and the National Center for 
Immunization and Respiratory Diseases. The survey began data 
collection in 1994 to monitor childhood immunization coverage and 
periodically surveys the status of adult immunizations. NHIS annually 
provides information on the health status of the U.S. civilian 
noninstitutionalized population through confidential interviews 
conducted in households. It is the nation's largest household health 
survey, providing data for analyses of health trends; determining 
barriers to care; and comparing health status, health-related 
behaviors, and risk factors across racial and ethnic populations. 

[12] While our focus in this report is on Medicare beneficiaries age 
65 and older, we also examined CDC data on adults age 60 to 64 because 
ACIP recommends shingles and Td/Tdap vaccinations for these ages and 
vaccinations received at ages 60 to 64 would still be effective when 
beneficiaries enrolled in Medicare at age 65. 

[13] Under Part D, every time a beneficiary fills a Part D 
prescription, the plan must submit a summary record called a 
prescription drug event to CMS containing specified information, such 
as the beneficiary identification number, date of service, provider 
identifier, dispensed drug, and beneficiary cost-sharing amount. Our 
analysis included prescription drug event data for beneficiaries age 
65 and older from 2007 through 2009 and excluded data for 
beneficiaries in employer plans, religious fraternal benefit plans, 
CMS demonstration plans, and programs of all-inclusive care for the 
elderly--because not all beneficiaries are allowed to enroll in those 
plans and programs. NHIS data from 2009 were the most recent available 
at the time of our review, and we used 2009 Medicare data to be 
comparable. 

[14] We refer to the District of Columbia as a state throughout this 
report. 

[15] Individuals age 65 and older are automatically enrolled in Part A 
if they are U.S. citizens or permanent legal residents and if they or 
their spouses are eligible for Social Security payments and have made 
payroll tax contributions for 10 or more years. Those individuals age 
65 and older who are not automatically enrolled may purchase Part A 
coverage. In this report, we use the term Medicare beneficiaries to 
refer to those individuals age 65 and older enrolled in Part A, and we 
consider Part A enrollment as the total Medicare enrollment. CMS 
reports that in 2010, less than 1 percent of Medicare beneficiaries 
were enrolled in Part B, but not in Part A. Beneficiaries must be 
enrolled in Part A or Part B to enroll in Part D. 

[16] An additional 7.5 million disabled individuals under age 65 were 
enrolled in Medicare Part A in 2009. 

[17] According to the Medicare Payment Advisory Commission (MedPAC), 
in 2009 most Medicare beneficiaries who did not elect Part D coverage 
had alternate drug coverage--such as employer-sponsored coverage or 
coverage through other federal programs--that was at least equal to 
Part D's defined standard benefit. See MedPAC, Report to the Congress: 
Medicare Payment Policy (Washington, D.C.: Mar. 2010), 286, accessed 
August 18, 2011, [hyperlink, 
http://www.medpac.gov/documents/Mar10_EntireReport.pdf]. 

[18] A deductible is an amount a beneficiary pays before Medicare will 
begin to pay--the Part A deductible for 2011 is $1,132, and the Part B 
deductible is $162. See CMS, Medicare and You (Baltimore, Md.: Feb. 
2011), accessed August 8, 2011, [hyperlink, 
http://www.medicare.gov/publications/pubs/pdf/10050.pdf]. A co-payment 
is usually a fixed amount paid by the beneficiary, such as $20 for an 
office visit, whereas coinsurance is a percentage of the item's or 
service's cost. 

[19] PPACA requires that Medicare Part B cover 100 percent of the 
charge for services recommended with a grade of A or B by the U.S. 
Preventive Services Task Force. Pub. L. No. 111-148, §§ 4104, 10406, 
124 Stat. 557, 975 (amending the Social Security Act (SSA) § 
1833(a)(1)). 

[20] Pub. L. No. 108-173, § 101, 117 Stat. 2066, 2071-2152 (adding a 
new Part D to title XVIII of the SSA, which establishes a voluntary 
Medicare prescription drug benefit program, including SSA § 1860D-2, 
which contains prescription drug benefit requirements). 

[21] Starting on January 1, 2011, a provision in PPACA reduced Part D 
beneficiaries' cost sharing in the coverage gap, or donut hole, by 50 
percent for applicable drugs and phases out the donut hole by 2020, at 
which time Part D beneficiaries' cost sharing will be 25 percent until 
beneficiaries' Part D drug costs reach the catastrophic threshold. See 
Pub. L. No. 111-148, § 3301, 124 Stat. 461 (as amended by the Health 
Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, § 
1101, 124 Stat 1029, 1036). 

[22] Pub. L. No. 108-173, § 101, 117 Stat. 2071-2152 (adding SSA § 
1860D-14, which establishes premium and cost-sharing subsidies for low-
income individuals). Under the Part D drug program, coverage for all 
Medicare beneficiaries is subsidized; however, LIS beneficiaries 
receive additional subsidy support. 

[23] The Part D population eligible for the LIS may be substantially 
greater. For example, according to a September 2010 report by the 
Henry J. Kaiser Family Foundation, more than 2 million Medicare 
beneficiaries were eligible for the LIS in 2009 but did not receive 
it. Most LIS beneficiaries received the full LIS, thus paying no 
premiums or deductibles as long as they enrolled in so-called 
"benchmark" stand-alone prescription drug plans. Benchmark plans are 
those plans with premiums at or below a specified benchmark for a 
given geographic region, as calculated by CMS. Full LIS beneficiaries 
may enroll in other Part D plans but must pay any difference between 
the premium of the plan in which they choose to enroll and the 
benchmark for their region. 

[24] For additional information on the schedule of adult vaccinations 
approved by ACIP for 2011, see CDC, "Recommended Adult Immunization 
Schedule--United States, 2011," Morbidity and Mortality Weekly Report, 
vol. 60, no.4 (2011), accessed February 22, 2011, [hyperlink, 
http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/mmwr-adult-
schedule.pdf]. 

[25] The hepatitis B vaccination is covered under Part B for 
beneficiaries at high or intermediate risk of contracting the disease 
based on certain behavioral and health factors, including residing in 
an institution for people with developmental disabilities, using 
injection drugs, receiving hemodialysis, or having end-stage renal 
disease. 

[26] In October 2010, ACIP revised its recommendation for Tdap. Adults 
age 65 years and older who have not previously received Tdap and who 
have close contact with an infant less than 12 months old should be 
vaccinated with Tdap, rather than Td, and other adults age 65 years 
and older may receive Tdap. Tdap can be administered regardless of the 
interval since the most recent Td/Tdap vaccination. In 2011, the Food 
and Drug Administration expanded the age indication for one Tdap 
vaccine for adults age 65 years and older. 

[27] As new adult vaccines are developed, licensed, and routinely 
recommended for Medicare beneficiaries, they will be covered under 
Part D unless coverage is specifically required under Part B. 

[28] We analyzed NHIS data for adults age 65 and older because this 
age group closely corresponds to the Medicare population. 

[29] While ACIP recommends that most people age 60 and older should 
receive a shingles vaccination, the vaccine is contraindicated for 
some of them, meaning they may have symptoms or conditions that would 
make the vaccination inadvisable. Contraindications for the shingles 
vaccination include certain immunocompromising conditions such as 
infection with the human immunodeficiency virus. Using Medicare data, 
we estimated that from 2 to 6 percent of Medicare beneficiaries age 65 
and older had at least one immunocompromising condition that could 
contraindicate the shingles vaccine from 2007 through 2009. 

[30] In December 2010, HHS announced its targets for Healthy People 
2020, the nation's 10-year goals and objectives for health promotion 
and disease prevention. Healthy People 2020 includes objectives with 
target rates for vaccination against specific diseases for different 
age groups. The target of 30 percent for shingles vaccination was 
established using 2008 NHIS data as a baseline, and progress toward 
the objective to increase the percentage of adults who are vaccinated 
against shingles will be measured using NHIS data. According to HHS, 
the shingles vaccination target was set in view of the many external 
barriers, including supply constraints. The 2008 NHIS data showed that 
7 percent of adults age 60 and older reported having ever received a 
shingles vaccination. Healthy People does not have a 2020 target for 
Td vaccination. See [hyperlink, 
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.as
px?topicId=23] (accessed Sept. 6, 2011). 

[31] To determine the percentage of Part D beneficiaries reimbursed 
for vaccinations that protect against tetanus and diphtheria, both 
with and without the pertussis component, we examined Part D data for 
both Td and Tdap. 

[32] These reimbursement figures include beneficiaries in the donut 
hole. 

[33] The other vaccinations reimbursed under Part D include those for 
hepatitis A; hepatitis B for individuals at low risk for contracting 
the disease; and travel-related illnesses, such as yellow fever. 

[34] MedPAC, Report to the Congress: Medicare Payment Policy. 

[35] To allow us to project to the national level, all statistics from 
our physician survey are weighted estimates. All percentage estimates 
from the survey have a margin of error at the 95 percent confidence 
level of plus or minus 8 percentage points or less, unless otherwise 
noted. In addition, our physician survey assumed that physicians who 
stock vaccines also administer them. 

[36] We surveyed providers on their common practices for the Part B-
covered pneumococcal vaccine as a comparison for their practices for 
the Part D-covered shingles and Td/Tdap vaccines. Similar to the 
shingles vaccination, the pneumococcal vaccination is generally a 
single-dose vaccination recommended for older adults. 

[37] E. Hing and C.W. Burt, "Characteristics of Office-Based 
Physicians and Their Medical Practices: United States, 2005-2006," 
National Center for Health Statistics. Vital and Health Statistics, 
series 13, no. 166 (2008). 

[38] The estimates for 1-or 2-physician and 3-to 10-physician 
practices have a margin of error above plus or minus 8 percentage 
points at the 95 percent confidence level. 

[39] Our survey did not collect data on how the vaccine was 
transported from the pharmacy to the physician's office for 
administration, and some methods of transporting the shingles vaccine 
are preferable to others. For example, pharmacies may ship or 
transport the vaccine to the physician's office, with attention to 
proper storage and handling. In other cases, however, beneficiaries 
may purchase the vaccine at a pharmacy and transport the vaccine to 
their physician's office themselves--a practice called brown-bagging. 
Brown-bagging of shingles vaccine is considered unacceptable by CDC 
because the vaccine's efficacy--its ability to provide a certain 
degree of protection--can be compromised if it is not kept frozen 
prior to administration. 

[40] Physician respondents were asked to classify 14 listed factors as 
a major barrier, a minor barrier, or not a barrier to stocking, 
administering, or recommending the shingles vaccine. The discussion 
here centers on the responses of physicians who do not stock the 
vaccine; for survey results for physicians who do stock the vaccine, 
see appendix IV. 

[41] These prices were reported by the shingles vaccine manufacturer 
to CDC. 

[42] In our survey of physicians, we also asked physicians who provide 
care to Medicare beneficiaries at nursing facilities whether Medicare 
beneficiaries residing in nursing homes face any unique difficulties 
accessing Part D vaccinations. Physicians generally indicated that 
these beneficiaries do not, although some physicians noted that 
nursing homes generally do not stock shingles or Td/Tdap vaccines. 
Nursing home administrators told us that they generally do not stock 
shingles or Td/Tdap vaccines; instead, they order them when attending 
physicians recommend the vaccinations. 

[43] The shingles vaccine is the only adult vaccine that must be 
stored frozen. To properly maintain a frozen supply of the vaccine, 
physicians must have a freezer that has a separate sealed freezer door 
and reliably maintains an average temperature of -15 degrees Celsius 
(+5 degrees Fahrenheit) or colder. The vaccine must be administered 
within 30 minutes of removal from the freezer. 

[44] To allow us to project to the national level, all statistics from 
our pharmacy survey are weighted estimates. All percentage estimates 
from the survey have a margin of error at the 95 percent confidence 
level of plus or minus 8 percentage points or less, unless otherwise 
noted. 

[45] Pharmacies were asked to classify the extent to which they 
offered and recommended routinely recommended vaccinations to 
beneficiaries, excluding influenza vaccinations. 

[46] Unlike the physician survey, our pharmacy survey did not assume 
that any pharmacy that stocks a vaccine administers it. 

[47] The estimate for the shingles vaccine has a margin of error above 
plus or minus 8 percentage points at the 95 percent confidence level. 

[48] For additional pharmacy survey results, see appendix V. 

[49] SHIPs were given a list of potential beneficiary difficulties and 
were asked to select the ones where they had encountered beneficiaries 
experiencing difficulty. We also asked SHIPs whether Medicare 
beneficiaries under age 65 experienced any unique difficulties 
accessing Part D-covered vaccinations, and SHIPs generally indicated 
that they do not. 

[50] Cost-sharing amounts include payments for applicable vaccine 
administration fees and apply to non-LIS beneficiaries age 65 and 
older. LIS beneficiaries generally have nominal cost sharing under 
Part D, including vaccines and administration fees. Prior to 2008, 
administration fees for Part D-covered vaccines were reimbursed by 
Part B. 

[51] L.P. Hurley et al., "National Survey of Primary Care Physicians 
Regarding Herpes Zoster and the Herpes Zoster Vaccine," Journal of 
Infectious Diseases, vol. 197, supp. 2 (2008): S216-S223. 

[52] In contrast, less than 1 percent of all other Part D 
reimbursements were submitted by beneficiaries. In 2009, Part D 
reimbursements for the shingles and Td/Tdap vaccinations accounted for 
0.07 percent of all reimbursements for beneficiaries age 65 and older. 

[53] For example, see CMS, "Reimbursement for Vaccines and Vaccine 
Administration Under Medicare Part D;" MLN Matters (2007), accessed 
September 26, 2011, [hyperlink, 
http://www.cms.gov/MLNMattersArticles/downloads/SE0727.pdf]. 

[54] Because Part D vaccination reimbursements are transactions with 
Part D plans, CMS does not provide physicians with access to such a 
web-based system. The private company that markets the system is 
TransactRx, which prior to 2010 was known as eDispense. We examined 
Part D data and found that in 2009, TransactRx processed about 10 
percent of all Part D shingles vaccination reimbursements. 

[55] A survey administered by one of our IOM discussion participants 
found that in 2008, 93 percent of physicians were not aware of such a 
system. L.P. Hurley et al., "Barriers to the Use of Herpes Zoster 
Vaccine," Annals of Internal Medicine, vol. 152, no. 9 (2010): 555-560. 

[56] See Medicare Program; Medicare Prescription Drug Benefit, 70 Fed. 
Reg. 4194, 4231, 4328 (Jan. 28, 2005) (discussion in preamble to final 
rule indicating that experience with Part D implementation will 
provide CMS with a better sense for the need and most appropriate 
mechanisms for such procedures). 

[57] Of the 22 articles, letters, and policy statements in our 
literature review that made recommendations for improving access to 
Part D-covered vaccinations, 20 recommended covering all vaccinations 
under Part B. These articles cited many of the same concerns raised by 
the IOM-facilitated discussion participants, such as physicians' out-
of-network status, and also provided support for the impact of these 
concerns, such as fewer physicians recommending Part D-covered 
vaccinations to their patients. Finally, our surveys found that 86 
percent of physicians believe it would be easier for physicians to 
stock and administer routinely recommended vaccines if they were under 
Part B and 39 of 51 SHIPs believe it would help improve beneficiary 
access to these vaccines if they were under Part B. 

[58] Medicare Improvements for Patients and Providers Act of 2008, 
Pub. L. No. 110-275, § 101(a)(1)(B), 122 Stat. 2494, 2496 (adding a 
new subsection (ddd) to SSA § 1861). 

[59] USPSTF typically assigns letter grades to preventive services it 
evaluates, recommending those services graded A or B for routine use 
in medical practice. However, USPSTF does not currently evaluate or 
make recommendations on vaccinations, instead referring to ACIP 
recommendations--acknowledging that ACIP's review methods may differ 
from its own. 

[60] See HHS, Report to Congress: Transitioning Medicare Part B 
Covered Drugs to Part D (Baltimore, Md.: 2005) (required by the 
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 
(MMA), Pub. L. No. 108-173, § 101, 117 Stat. 2066, 2150 (adding SSA § 
1860D-42(c) (codified at 42 U.S.C. § 1395w-101 note)). 

[61] CBO, Estimate of the Effects on the Deficit of H.R.3962, the 
Affordable Health Care for America Act, as Passed by the House of 
Representatives (Nov. 20, 2009). 

[62] According to MedPAC staff, CBO does not provide specific 
estimates for the cost of the commission's recommendations; instead, 
CBO classifies those estimated costs within buckets of cost range 
estimates. The ranges of $0 to $50 million for 1 year and $0 to $1 
billion for 5 years were CBO's smallest cost increase estimate buckets 
for 1 and 5 years, respectively. 

[63] G. Marrufo et al., Estimating the Effects of Consolidating Drugs 
under Part D or Part B (Acumen, LLC, Sept. 2011). The study analyzed 
data for Part D beneficiaries who received vaccinations covered under 
Part D in 2007 and estimated the change in costs to both Part D 
beneficiaries and the Medicare program had the vaccinations been paid 
for by Part B. 

[64] Pub. L. No. 111-148, § 1001, 124 Stat. 130 (adding § 2713 to the 
Public Health Service Act). Private health care plans in existence as 
of March 23, 2010, are considered grandfathered plans that do not have 
to comply with certain PPACA coverage requirements, including first-
dollar coverage for vaccinations. See Pub. L. No. 111-148, § 1251, 124 
Stat. 161. However, plans will lose their grandfathered status if they 
significantly cut benefits or increase beneficiary cost sharing. HHS, 
in conjunction with the Departments of the Treasury and Labor, 
estimated that a substantial fraction of plans will enact changes and 
relinquish their grandfathered status. For example, the departments 
estimated that from 39 percent to 69 percent of private employer-
sponsored plans will relinquish their grandfathered status by 2013. 
See, Interim Final Rules for Group Health Plans and Health Insurance 
Coverage Relating to Status as a Grandfathered Health Plan Under the 
Patient Protection and Affordable Care Act, 75 Fed. Reg. 34538, 34553, 
34557 (June 17, 2010) (provisions relating to maintenance of 
grandfather status codified at 26 C.F.R. § 54.9815--1251T(g), 29 
C.F.R. § 2590.715--1251 and 45 C.F.R. § 147.140). 

[65] National Association of Chain Drug Stores officials and most 
surveyed pharmacies--69 percent--reported that another way to increase 
access to all vaccinations would be to cover them under Part D because 
pharmacies, as in-network Part D providers, can more easily check 
beneficiaries' coverage and submit reimbursements. 

[66] The National Vaccine Advisory Committee makes recommendations to 
the Director of the Department of Health and Human Services' National 
Vaccine Program, which is responsible for coordinating and ensuring 
collaboration among federal agencies involved in vaccination and 
immunization activities. 

[67] The organization was formerly known as the American Association 
of Retired Persons. 

[68] The most recent NHIS data available for our analysis were those 
from 2009. 

[69] CDC, "Prevention of Herpes Zoster: Recommendations of the 
Advisory Committee on Immunization Practices (ACIP)," Morbidity and 
Mortality Weekly Report, vol. 57, no. 05 (2008): 1-30. 

[70] The most recent Hierarchical Condition Categories (a 
classification system used by CMS to group certain medical conditions) 
data available for our analysis were those from 2008. 

[71] We used data from the Healthcare Common Procedure Coding System 
to identify fee-for-service claims in which beneficiaries utilized a 
drug associated with an immunocompromising condition. 

[72] State-level vaccination rates were calculated using 2009 Medicare 
Part B and Part D data. 

[73] Physician vaccination rates were calculated using 2009 Medicare 
Part B and Part D data. 

[74] State-level vaccination rates were calculated using 2009 Medicare 
Part B and Part D data. 

[75] Pharmacy vaccination rates were calculated using 2009 Medicare 
Part D data. 

[76] Several members represented both professional organizations and 
advisory bodies. 

[77] Shingles is not a notifiable condition in the United States, 
meaning that health care providers are not required to notify 
authorities of cases of shingles. Shingles incidence has been inferred 
from a variety of studies, including national health surveys, patient 
records, and health plan data. See CDC, "Prevention of Herpes Zoster: 
Recommendations of the Advisory Committee on Immunization Practices 
(ACIP)," Morbidity and Mortality Weekly Report, vol. 57, no. 05 
(2008): 1-30. 

[78] Merck & Co., Inc. is the sole manufacturer of Zostavax. 

[79] The standard Part D benefit includes an annual deductible and 
consists of three phases: (1) an initial phase with coverage up to a 
specified level of spending, (2) a coverage gap when beneficiaries pay 
a greater portion of the cost of their drugs, and (3) a catastrophic 
phase where beneficiary cost sharing is minimal. 

[80] This provision phases out the donut hole by 2020, at which time 
Part D beneficiaries' cost sharing will be 25 percent of the cost of 
the vaccine until beneficiaries' Part D drug costs reach the 
catastrophic threshold. See Pub. L. No. 111-148, § 3301, 124 Stat. 461 
(as amended by the Health Care and Education Reconciliation Act of 
2010, Pub. L. No. 111-152, § 1101, 124 Stat 1029, 1036). 

[End of section] 

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