Vaccines for C difficile: Reviewing the Reimbursement Environment

Norm Smith, former president, Viewpoint Consulting, reflects on a project where his company was once asked to look at reimbursement models linked with C difficile vaccines in countries outside of the United States, and highlights why this is still going to be an ongoing field that should be of interest to both the hospital and the community health care provider.

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

I'm Norm Smith. I was president of Viewpoint Consulting for 20 years. We were a firm that was involved with payer issues, reimbursement issues, pricing, and contracting issues. Largely in the United States, but in a number of projects we had a worldwide reach.

What we were asked to do by a manufacturer was to look at the reimbursement environment for C difficile vaccines. C difficile, of course, can be both hospital and community acquired. This was more about looking at it from both the hospital side originally and then would there be protection for a patient once they're out in the community.

The challenge of this was in Western Europe and Canada. The question was, since these are largely government pay countries, and in most cases now they do pay for other vaccines. In the case of C difficile vaccine, it became a little more complicated—or maybe a lot more complicated.

The question was, would this be something that would be universally used? From the way we were guided from the manufacturer was they don't think so. They think high risk people would be the ones to be vaccinated. Then the question is, would this become a standard of care in those countries? If so, who would pay for it?

What we were asked to do was not to speak to the decision makers among the government payers. What we were asked to do was to talk to those insurers who act as complementary insurers to government programs in five EU countries and Canada. There are countries just like that that provide additional insurance for products that the government decides for whatever reason, cost, efficacy, safety, they decide not to cover.

The most well-known example was for certain cancers in Great Britain. There's a separate fund that insures for some of the newer biologic cancer products. With C diff, the risk of C diff varies tremendously from country to country.

In England, it's a very high-risk area. It's something that hospitals have to report on a monthly basis. It goes to parliament. They have a major problem within the English health care system. In a country like that, this vaccine may be given to a larger group of patients.

In Spain, the decisions are generally on a hospital level. The insurers there—the complimentary insurers, not the government insurers—said, we have to look at which hospital or patient is treated in. If there was a recurrence in someone who had been moved into the outpatient environment, then that would be another case. But always by exception rather than by rule.

In France they were quite anxious to have this. I gather that's a bigger problem than we could uncover, but in some hospitals there it was a serious problem much like it was in England. Part of what came out of this was the concern on the part of these complimentary insurers on pricing.

While most vaccines are relatively inexpensive, my understanding from the manufacturer that employed us was that would not be the case here. Because this would not be used in a large population. The price range for these products would be consistently higher than for other vaccines.

When we concluded this and wrote the report, the report basically said there's a need for this product and there is certainly a willingness to pay among these complimentary payers that was relatively high. They recognized this was not going to be a mass vaccination issue. That is where this sits as of today. I understand back in September some of the phase two studies for one of the products were stopped based on injection site redness as a side effect.

This is still going to be an ongoing field that should be of interest both to the hospital and the community health care provider.

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