Protecting Newborns from RSV: Opening a Reimbursement Pathway

Richard H. Hughes IV, Devon R. Minnick, Marjorie Scher, and Ada Peters, attorneys in the Health Care & Life Sciences practice, co-authored an article in Health Affairs, titled "Protecting Newborns from RSV: Opening a Reimbursement Pathway."

Following is an excerpt:

Respiratory syncytial virus (RSV) is a cold-like illness that can be dangerous for infants, especially those born during the respiratory season. We finally have a tool to protect them, yet entrenched reimbursement models may stand in the way, disincentivizing providers in hospital labor and delivery units from offering it.

Nirsevimab is a long-acting monoclonal antibody designed to provide passive immunity against RSV in infants and young children. The Advisory Committee on Immunization Practices (ACIP) recommends routine administration of nirsevimab for infants under 8 months born during the RSV season (September to March), depending on the mother's RSV vaccination status.

Importantly, ACIP recommends that nirsevimab be administered within one week of birth, either during the birth hospitalization or in an outpatient setting. However, the Centers for Disease Control and Prevention (CDC) underscores the importance of timely administration, recommending that, ideally, babies born October through March receive nirsevimab during their birth hospitalization. A missed hospital administration is especially concerning, considering that around 15 percent of new parents may not attend a follow-up visit in a timely manner.

The Vaccines for Children (VFC) program provides free doses for children born into lower-income families if the hospital participates in the program. But the conventional labor and delivery bundle used by commercial payors to reimburse hospitals for a birthing episode does not account for the added cost of nirsevimab. This unique impediment disproportionately impacts the timely administration of nirsevimab for commercially insured infants, including those in marketplace plans whose family income only marginally exceeds the Medicaid eligibility cap in their state.

Negotiating separate reimbursement between hospitals and payers outside of standard bundled payment would best resolve these barriers. State and federal agencies should provide reinforcement to encourage, if not require, these arrangements.