SETTING THE COURSE

A STRATEGIC VISION FOR IMMUNIZATION

PART 3 SUMMARY OF THE LOS ANGELES WORKSHOP

Committee on the Immunization Finance Dissemination Workshops

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu



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SETTING THE COURSE A STRATEGIC VISION FOR IMMUNIZATION PART 3 SUMMARY OF THE LOS ANGELES WORKSHOP Committee on the Immunization Finance Dissemination Workshops Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS500 FIFTH STREET, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Centers for Disease Control and Prevention. The views presented in this report are those of the Institute of Medicine Committee on the Immunization Finance Dissemination Workshops and are not necessarily those of the funding agencies. International Standard Book Number 0-309-08712-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE IMMUNIZATION FINANCE DISSEMINATION WORKSHOPS DAVID R. SMITH, M.D. (Chair), President, Texas Tech University Health Sciences Center, Lubbock, TX BRIAN BILES, M.D., Professor and Chair, Department of Health Services Management and Policy, The George Washington University STEVE BLACK, M.D., Co-Director, Vaccine Study Center, Kaiser Permanente, Oakland, CA GORDON H. DeFRIESE, Ph.D., President and Chief Executive Officer, North Carolina Institute of Medicine, Woodcroft Professional Center, Durham DIANNE WHITE DELISI, M.A., State Representative, Texas House of Representatives R. GORDON DOUGLAS, JR., M.D., Former President, Merck Vaccines (retired), Princeton, NJ JONATHAN FIELDING, M.D., M.P.H., Director of Public Health and Health Officer, Los Angeles County Department of Health Services MAXINE HAYES, M.D., M.P.H., State Health Officer, Washington State Department of Health, Olympia ROBERT L. JOHNSON, M.D., Professor and Chair, Division of Adolescent and Young Adult Medicine, University of Medicine and Dentistry of New Jersey–New Jersey Medical School SAMUEL L. KATZ, M.D., Wilburt C. Davison Professor Emeritus, Department of Pediatrics, Duke University Medical Center WILLIAM KISSICK, M.D., M.P.H., Dr.P.H., George Seckel Pepper Professor of Public Health, The Leonard Davis Institute, The Wharton School, Philadelphia RONALD J. SALDARINI, Ph.D., President, Wyeth Lederle Vaccines and Pediatrics (retired), Mahwah, NJ WILLIAM SCHAFFNER, M.D., Professor and Chairman, Department of Preventive Medicine, Vanderbilt University School of Medicine GARTH SPLINTER, M.D., M.B.A., Associate Professor, Chief Medical Officer, University Hospital Trust, Oklahoma City, OK Committee Staff ROSEMARY CHALK, Senior Program Officer JANE DURCH, Consultant RYAN PALUGOD, Senior Project Assistant

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ACKNOWLEDGMENTS The Institute of Medicine workshop on immunization finance was organized through the efforts of numerous health care organizations and health care providers throughout the state of California. We acknowledge in particular the logistical support and gracious hospitality of the faculty and staff of the School of Public Health at the University of California in Los Angeles, under the leadership of Dean Linda Rosenstock and the guidance and assistance of Karen Markus. Natalie Smith and John Dunajski from the Immunization Branch of the California State Department of Health provided valuable guidance in identifying expert resources throughout the state. Jonathan Fielding, Cheri Todoroff, and David Gambill from the Los Angeles County Department of Health, Sandra Ross from the San Diego County Department of Health, and Kristin Brusuelas from the National Immunization Program of the Centers for Disease Control and Prevention did the same in pointing us toward experts in the Los Angeles and San Diego areas. Lynn Denton from the Texas Department of Health and Richard Butler from the Texas Tech University Health Sciences Center also provided helpful assistance and support in preparing for the workshop. Additional guidance was provided by the Pacific Business Group on Health, the California chapters of the American Academy of Pediatrics, the California Medical Association, Michael Marcy from Kaiser Permanente in Los Angeles, and Steve Baranov from Immunize LA Kids. Staff from the National Immunization Program of the Centers for Disease Control and Prevention in Atlanta helped to identify immunization program directors and public health advisers throughout the state of California and also prepared data analyses and exhibits to inform the workshop discussions. The Center for the Advancement of Distance Education at the University of Illinois provided on-site technical support in audiocasting the January 17 workshop to a national audience. An archival file of the speakers’ remarks and electronic slides can be found at the IOM website: www.iom.edu/iom/iomhome.nsf/pages/hcs+immunization+finance+dissemination.

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REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Bernard Guyer, M.D., M.P.H., The Johns Hopkins University Sara Rosenbaum, J.D., The George Washington University Sandra Ross, P.H.N., Health and Human Services Agency, San Diego, CA Cheri Todoroff, M.P.H., Los Angeles Immunization Program Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions nor did they see the final draft of the report before its release. The review of this report was overseen by Neal A. Vanselow, M.D., Rio Verde, Arizona. Appointed by the National Research Council and Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Contents     EXECUTIVE SUMMARY   1     INTRODUCTION   4     BACKGROUND   6     A NATIONAL PERSPECTIVE ON THE IMMUNIZATION SYSTEM   8     The National Immunization Picture,   8     Challenges for the Immunization System,   11     IOM Conclusions and Recommendations,   13     CDC Responses to IOM Recommendations,   15     STATE AND LOCAL IMMUNIZATION ISSUES IN CALIFORNIA   18     California Department of Health Services,   18     Los Angeles County,   21     San Diego County,   23     Observations from IOM Case Studies,   25     Discussion,   28     PRACTICAL CHALLENGES FOR PRIVATE PROVIDERS   29     Challenges for the Private Provider in California,   29     Office Operations and Delivery of Immunization Services,   32

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    HEALTH PLANS AND EMPLOYERS   36     Health Plan Perspectives,   36     An Employer’s View of Immunization Coverage,   39     CONCLUDING OBSERVATIONS   41     REFERENCES   43     APPENDIXES         A Workshop Agenda   47     B Workshop Participants   50     C Website Referrals   55

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Tables, Figures, and Box TABLES 1   Change in annual morbidity from vaccine-preventable diseases: Prevaccine baseline and 2001,   9 2   Estimated vaccination coverage for the 4:3:1:3 series among children ages 19 to 35 months, United States and California, 1996–2000,   19 3   Vaccine-preventable diseases, Los Angeles County, 1990–2000,   21 FIGURES 1   Estimated vaccination coverage with the 4:3:1:3 series, by coverage level and state,   10 2   Six roles of the national immunization system,   14 3   Sources of eligibility for children participating in the Vaccines for Children (VFC) program in Los Angeles and San Diego counties, 1999,   27 BOX 1   Partial list of necessary procedures to immunize a child,   32

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