Optimizing RSV vaccination in U.S. older adults: Cost-effectiveness insights, payer coverage strategies and implementation pathways

Respiratory syncytial virus places a heavy burden on older adults in the United States, leading to considerable respiratory morbidity, frequent hospitalizations, and high healthcare costs. Approval of RSV vaccines for adults aged 60 years and older has moved prevention toward immunization. Reliable economic evaluations are crucial for guiding coverage and policy decisions. This review, the second in a two-part series, synthesizes U.S.-specific cost-effectiveness evidence for RSV vaccination in this population and addresses implications for payer strategies, clinical adoption, and health system alignment. Societal-perspective analyses show favorable value, with incremental cost-effectiveness ratios well below standard U.S. willingness-to-pay thresholds of $100,000 to $150,000 per quality-adjusted life-year. Payer-perspective analyses produce higher ratios because they exclude indirect costs and broader societal benefits. The analytical perspective is the primary factor influencing conclusions, followed by hospitalization costs, vaccine efficacy, and the duration of protection. Effective implementation depends on budget offsets, aligning quality metrics, accurate coding, and risk adjustment. RSV vaccination offers significant economic value within frameworks relevant to decision-makers. Incorporating societal benefits more fully into payer assessments would promote sustained coverage and greater uptake.