Challenges Facing the Immunization System

Despite improvements in immunization coverage during the 1990s, national immunization rates for 2 year olds and older adults have not yet reached the public health objective of 90 percent coverage. Although state-level rates in Illinois and Michigan are generally equiva-lent to the U.S. national average, substantial variation in coverage rates occurs between states as well as within each state. The nation’s immunization system faces serious challenges that could undermine the progress that has been made and hinder the effort still needed to achieve targeted levels of immunization coverage. Some of these demands include sustaining current rates of coverage with the addition of new and more expensive vaccines to the immunization schedule, an increase in the number of people to serve as a result of recommendations for adolescent and adult vaccination, and changes in the health care delivery system in general and immunization services in particular that can affect the availability and affordability of vaccines in the private sector.

The workshop discussions covered several broad national concerns about the immunization system as well as issues of specific concern at the state level in Illinois and Michigan and at the local level in Chicago and Detroit. The six roles of the immunization system identified in Calling the Shots are used as a framework for reviewing these discussions.

CONTROLLING AND PREVENTING INFECTIOUS DISEASE

The central purpose of the immunization system is to reduce or elimi-nate illness and death from vaccine-preventable diseases. In their remarks,



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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop Challenges Facing the Immunization System Despite improvements in immunization coverage during the 1990s, national immunization rates for 2 year olds and older adults have not yet reached the public health objective of 90 percent coverage. Although state-level rates in Illinois and Michigan are generally equiva-lent to the U.S. national average, substantial variation in coverage rates occurs between states as well as within each state. The nation’s immunization system faces serious challenges that could undermine the progress that has been made and hinder the effort still needed to achieve targeted levels of immunization coverage. Some of these demands include sustaining current rates of coverage with the addition of new and more expensive vaccines to the immunization schedule, an increase in the number of people to serve as a result of recommendations for adolescent and adult vaccination, and changes in the health care delivery system in general and immunization services in particular that can affect the availability and affordability of vaccines in the private sector. The workshop discussions covered several broad national concerns about the immunization system as well as issues of specific concern at the state level in Illinois and Michigan and at the local level in Chicago and Detroit. The six roles of the immunization system identified in Calling the Shots are used as a framework for reviewing these discussions. CONTROLLING AND PREVENTING INFECTIOUS DISEASE The central purpose of the immunization system is to reduce or elimi-nate illness and death from vaccine-preventable diseases. In their remarks,

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop Samuel Katz provided an overview of the tremendous impact of vaccines on the infectious disease burden in the United States (Table 1), while Gillian Stoltman drew attention to state-level effects in Michigan (Figure 2 ). The reduced burden of illness represents significant improvements in both mortality rates and the quality of life in each community, as well as cost savings for local and state health agencies, since public hospitals no longer need to care for patients affected by vaccine-preventable disease. Workshop participants noted that achieving high levels of immunization coverage not only offers immediate protection of vaccinated individuals but also conveys long-term benefits by reducing the reservoir of disease and hence the number of future cases in the general population. The nation is fortunate that the renewed attention to early childhood immunization following the 1989–1991 measles outbreak has helped achieve historically high levels of vaccine-preventable childhood diseases. Despite best efforts, however, the nation as a whole and most individual states did not reach the national health goals of 90 percent coverage rates for recommended childhood vaccines by the year 2000 (Table 2). Workshop participants emphasized, however, that as long as infectious disease reservoirs remain, children who have not been adequately vaccinated are still at risk. They also commented that lack of familiarity with the seriousness of vaccine-preventable diseases and the increasing prominence of concerns about the safety of some vaccines may contribute to delays in vaccination. As reported in Calling the Shots, about 300 children die each TABLE 1 Comparison of 20th-Century Maximum (Year) and Current Morbidity of Vaccine-Preventable Diseases Disease Maximum Cases (Year) 2000 Provisional % Decrease Smallpox 48,164 (est.) 0 100.00 Diphtheria 206,939 (1921) 1 100.00 Measles 894,134 (1941) 86 99.98 Mumps 152,209 (1968) 338 99.80 Pertussis 265,269 (1934) 7,867 95.50 Polio (paralytic) 21,269 (1952) 0 100.00 Rubella 57,686 (1969) 176 99.60 Congenital rubella syndrome 20,000 (1964-65) 9 98.90 Tetanus 1,560 (1923) 35 97.30 Haemophilus influenzae   Type B and unknown   (< 5 years) 20,000 (est.) 167 99.20 SOURCE: CDC (2001a).

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop FIGURE 2 Impact of immunization on disease in Michigan. SOURCE: Gillian Stoltman, Michigan Department of Community Health. IOM workshop presentation. 2001.

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop TABLE 2 Estimated Vaccination Rates for Selected Vaccines and Vaccine Combinations, 2000   Healthy People 2010 Goal % United States % Illinois % Chicago % Michigan % Detroit % Children ages 19-35 months 4:3:1:3 series* = 90 78 75 65 75 59 Adults ages 65 and older Influenza** = 90 67 68 — 70 — Pneumococcal pneumonia** = 90 54 47 — 58 — *Four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of any measles-containing vaccine, and three or more doses of Hib vaccine. SOURCES: *CDC (2000c); National Immunization Survey (www.cdc.gov/nip/coverage/default.htm). **CDC (2001b); Behavioral Risk Factor Surveillance System (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5025a2.htm). year from these potentially preventable diseases or their complications. And the burden of mortality and morbidity in the adult population is significantly greater, as will be discussed later. Participants indicated that immunization coverage rates for children in urban areas such as Chicago and Detroit tend to be lower than state averages—and lower still in some disadvantaged neighborhoods in those cities. A disturbing decline in immunization rates is evident in both Chicago and Detroit (see Table 3). In Chicago, coverage was at 74 percent in 1996 but dropped to 59 percent in 2000. In Detroit, reported coverage levels peaked at 70 percent in 1998 but dropped to 59 percent in 1999 before increasing to 62 percent in 2000. More extensive international travel was cited as posing known risks of importing disease that can spread among unprotected children in such communities. Children in families of undocumented immigrants may be at special risk and pose an added risk to the community if they are underimmunized and their families are apprehensive about using health care services. William Schaffner from Vanderbilt University contrasted the relative success in preventing disease in children with adults’ continued high rates of illness and death related to vaccine-preventable diseases, including influenza, pneumococcal disease, and hepatitis B. He estimated that

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop TABLE 3 Estimated Vaccination Coverage for the 4:3:1:3* Series Among Children Ages 19-35 Months, 1996-2000   1996 % 1997 % 1998 % 1999 % 2000 % United States 78 76 79 78 76 Illinois 75 74 78 77 75 Chicago 74 68 64 71 65 Michigan 74 75 78 74 75 Detroit 63 65 70 66 59 *Four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of any measles-containing vaccine, and three or more doses of Hib vaccine. SOURCES: CDC (1997, 1998, 2000a, b, c); National Immunization Survey (www.cdc.gov/nip/coverage/default.htm). about 30,000 deaths per year might be preventable with full immunization among adults. Rates of immunization for influenza and pneumococcal disease among the elderly and younger adults with chronic illnesses and other high-risk conditions are persistently low, maintaining a large vulnerable population that contributes to the spread of disease. The IOM report Calling the Shots drew particular attention to the difficulties in providing routine access to vaccines for disadvantaged members in this “younger” adult population with chronic health disorders, who are not eligible for Medicare and who are often treated by specialists who are not familiar with immunization recommendations rather than primary care physicians. ASSURING VACCINE PURCHASE Immunization programs are possible because of the availability of highly effective vaccines. The Vaccines for Children program distributes federally purchased vaccines directly to health care providers for use in immunizing children who depend on Medicaid for their health care services or who are uninsured or qualify under additional categories of eligibility. In addition, states receive annual federal grants through the Section 317 program to support the purchase of vaccines, primarily for children. Dr. Stoltman observed, for example, that the state of Michigan relies on different federal funding streams for 73 percent of the total cost of vaccines that are distributed by local health departments, and the bulk of this

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop public purchase (57 percent) is supported by the funds they received from the CDC. Most states also use their own funds to purchase additional vaccine, but the size and sources of this investment vary. For example, Michigan uses part of its tobacco tax revenues to support vaccine purchases, accounting for 17 percent of its total state purchase. Gary Freed from the University of Michigan presented data that describe the range of state practices with respect to vaccine purchase and immunization program support. Some “universal purchase” states have adopted policies to ensure that all children in the state who do not have private health plan coverage have access to vaccines. But workshop participants expressed concern about the increasing cost of purchasing adequate supplies of vaccine. These costs are causing some states to recon-sider their commitment to universal purchase policies. Vaccine Costs In Calling the Shots, the IOM recognized an immediate need for additional federal and state funding to support the purchase of vaccines for uninsured and underinsured adolescents and adults. CDC representatives at the workshop noted that although states have had the option to use Section 317 funds to purchase adult vaccines, few have done so. The need for these vaccines is expanding as immunization recommendations are extended beyond the elderly to younger age groups. Although past federal and state funding for purchase of pediatric vaccines was judged adequate by the IOM, the addition to the recommended immunization schedule of new, more expensive vaccines makes reassessment of those funding levels necessary. In particular, the high cost of the new pneumococcal conjugate vaccine was noted. With the addition of this and other new vaccines, as well as additional doses of older vaccines, to the recommended immunization schedule, workshop speakers noted that the per-child cost, at federal contract prices, of all vaccines for preschool immunization is approaching $400. The cost is even higher for vaccines purchased at manufacturers’ catalogue prices. The budgetary impact is particularly severe in universal purchase states. Workshop participants affirmed the importance of the IOM recommendation for regular evaluation of vaccine purchase budgets. Gillian Stoltman from the Michigan Department of Community Health presented trend data that illustrated the recent impact of the cost of the new pneumococcal conjugate vaccine, which was added to the recommended immunization schedule in 2000 (after the IOM committee concluded its deliberations; see Figure 3). At a federal contract price of $45.99 per dose in 2001 (see www.cdc.gov/nip/vfc/cdc_vaccine_price_list.htm), pneumococcal conjugate vaccine is more expensive than any other recommended vaccine. The total

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop FIGURE 3 Vaccine costs in Michigan, 1995-2001. SOURCE: Gillian Stoltman, Michigan Department of Community Health. IOM workshop presentation. 2001

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop cost of a full four-dose series exceeds the combined cost of all other vaccines that children should receive by age 2. Workshop participants also pointed to the financial burdens caused by delays between the official recommendation for use of a vaccine and the establishment of a federal contract for purchase of the vaccine at a reduced price. For example, an official recommendation by the Advisory Committee on Immunization Practices (ACIP) creates an immediate obli-gation to provide the vaccine to children eligible for some public-sector programs, such as VFC. Among the privately insured, requests for newly recommended vaccines may grow before coverage is added to their own health plan benefits. If private providers hesitate to offer a vaccine for which they must charge full price, parents may also be reluctant to pay full price. As a result, significant delays may occur in the administration of recommended vaccines. And greater numbers of children may be referred to health departments to obtain these new vaccines at low or no cost, thus adding to the demand for publicly purchased vaccine. Finally, some private health care providers are reluctant to participate in the VFC program, even though they provide primary care to eligible children. The paperwork requirements associated with the VFC purchase plan have discouraged some providers from offering the vaccines to disadvantaged children as part of their primary care in a “medical home.” These providers continue to send children to the local public clinic, creating a steady demand for immunization services in a public health setting. Vaccine Production Because vaccines represent only a small segment of the pharmaceuti-cal market and most vaccines are produced by only four major firms, the vaccine supply is vulnerable to manufacturing problems and to market economics. Production problems created temporary shortages of diph-theria, tetanus, and acellular pertussis (DTaP) vaccine and delayed the delivery of influenza vaccine in 2000. The supply of tetanus vaccine, which is produced by a single manufacturer, has also been disrupted. A dys-functional purchasing system was cited at the workshop as adding to the problems in obtaining adequate and timely supplies of influenza vaccine, especially when manufacturers decide to discontinue a product on short notice. And despite concerns about the high prices of new vaccines, the realities of the vaccine marketplace were acknowledged: manufacturers must receive sufficient economic benefit from vaccines to be willing to continue producing them. Workshop participants suggested that the federal government needs to assume a stronger role in assuring the produc-tion of vaccines for the general population as well as continuing its tradi-

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop tional role of providing a safety net in supplying vaccines for disadvantaged groups. ASSURING SERVICE DELIVERY Ensuring the adequacy of the vaccine supply is essential for achieving immunization goals, but the presence of sufficient stocks of vaccine does not ensure that they will be delivered or distributed equitably within the health care system. The workshop discussions highlighted two concerns related to the delivery of immunization services. One of these concerns was the effect of limitations in coverage (both exclusions and temporary delays in benefits for new vaccines) for immunization services under private health insurance plans. The other concern was related to the availability of immunization services for children with publicly funded health insurance. Participants also commented on the added burden that immunization services can impose on health departments and other public-sector programs. Private Health Insurance Coverage For both children and adults, the use and availability of immunization services are influenced by the scope of insurance benefits for those services. Almost all older adults (>65 years) are eligible for Medicare and its coverage for virtually all recommended vaccines, including influenza, pneumococcal, and hepatitis B. However, they may still rely on a mix of Medicare and private insurance benefits for coverage of other vaccination services, such as routine tetanus-diphtheria toxoid vaccine (Td). The coverage of immunization services for preschool children under private insurance plans is good but may offer only partial coverage of costs or require payment of plan deductibles before covering immunizations. For older children, adolescents, and adults under age 65, private health insurance benefits for immunization services vary in scope and are often more limited than those for the youngest children. For example, one major automobile manufacturer reportedly offers a health insurance plan that covers immunization only up to age 5. And John Wilhelm from the Chicago Department of Health noted that even health plans offered by state or local governments may not include full coverage of immunization services. Coverage of immunization services depends, in part, on choices made by benefits managers for employers and others (such as labor unions) who are involved in the decision-making process involving purchases of private health insurance. Workshop participants pointed to the importance of educating purchasers and consumers about the value and recommended use of immunizations for people of all ages. In addition, more

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop aggressive efforts to inform benefits managers about new vaccines for preschool children might help speed decisions to offer coverage for those vaccines. A related concern is delays in coverage of new vaccines by health plans. One workshop speaker commented that even though the health benefits of the new pneumococcal conjugate vaccine for children had been evident for several months before the formal ACIP recommendation for its use, several health plans in Michigan still required several months following the ACIP action to resolve coverage questions. Market factors also influence decisions about health insurance benefits packages. In a tight labor market, generous health insurance benefits may be used to attract and retain workers, but in other circumstances, benefits may be restricted and reduced to control costs. In an example cited at the workshop, a major labor union reportedly decided to exclude coverage for Hib vaccine to discourage selection of the most expensive health plan. Although some groups advocate requiring coverage of all costs for all recommended immunizations, some workshop participants expressed concern over this approach. Because most private health insurance is offered on a voluntary basis, often by employers, mandating coverage for immunizations or other medical services might discourage some employers from offering health insurance benefits or raise health plan costs to levels that employees felt they could not afford. Availability of Immunization Services Under Public Health Insurance Programs Immunization benefits differ between public insurance programs (Medicaid, State Child Health Insurance Program (SCHIP), and Vaccines for Children) and private plans both for the preschool population and older adolescents (ages 18-21), which fragments their access to vaccines. Yet even when child and adolescent populations have coverage for all recommended vaccines, workshop participants pointed to problems in obtaining immunization services. Some children lack easy access to participating health care providers. For example, although CDC reported that more than 40,000 health care providers are participating in VFC (Rodewald presentation), children living in rural areas can still have diffi-culty finding participating providers. For underinsured children (i.e., those with health insurance but without coverage for recommended immunizations), the challenge is finding federally qualified health centers or rural health clinics, their only VFC-authorized sources of immunization services. The amount of turnover in Medicaid enrollment populations also challenges efforts to provide immunization services from a single or small

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop group of providers and health plans that have access to the child’s health records. Rachel Block from the Center for Medicaid and State Operations within the Health Care Financing Administration presented data illus-trating the range of variation in Medicaid enrollment figures among states. At the end of 6 months, many states have less than 50 percent of their 2-year-old population continuously enrolled in Medicaid plans (Table 4). This change in enrollment figures affects health care providers as well, many of whom may see an infant or child only once or twice before the family’s eligibility for Medicaid assistance changes because of income dynamics or eligibility criteria. Children in urban areas also may have problems obtaining the immunization services for which they are eligible because of confusion and instability in Medicaid managed care services. Workshop participants from Michigan and Detroit, for example, reported that confusion on the part of parents and Medicaid providers about coverage and eligibility for Medicaid and VFC services results in referrals of some children to public clinics for immunizations covered by VFC. Paul Giblin from the Children’s Hospital in Detroit presented disturbing findings from a Detroit immunization study that examined factors that might be contributing to the city’s TABLE 4 Percentage of 2 Year Olds in Medicaid and Managed Care Plans Who Were Continuously Enrolled in the Same Plan at 6 and 12 Months Prior to Their Second Birthdays States Year 6 Months 6 Months with One-Month Break 12 Months 12 Months with One-Month Break A 2000 (CY) 45% 51% 30% 33% B 1999 (CY) 79%   56%   C 99-00 (SY) 10% 30% 5% 15% D 1999 (CY) 40% 71% 16% 21% E 2000 (CY) 87% 89% 87% 88% F 2000 (CY) 59% 73% 49% 62% G 2000 (CY) 47% 55% 32% 39% H 2000 (CY) 46% 55% 37% 47% I 1999 (CY) 25% 31% 13% 18% Average (weighted) 48% 62% 34% 45% CY=calendar year SY=state year SOURCE: G. Fairbrother, unpublished data collected for CDC. 2001.

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop declining immunization rates. In the east side of Detroit, 10 primary care clinics closed during the 5-year project period, requiring families to locate new sources of care. In addition, between July 1999 and April 2001, the number of health plans offering Medicaid managed care services in Wayne County (which includes Detroit) dropped from 16 to 9 and the number of enrollees served by those plans dropped by almost 35,000. In reviews of immunization records in nine clinics, the project found that as many as 30 percent of the children who had been seen at one time could not be accounted for at the time of the review. All of these findings point to a lack of continuity of care for many children, which can interfere with the timeliness of immunizations and with the completeness and accuracy of immunization records. Adults between the ages of 21 and 65 who do not have private insurance are eligible for Medicaid (and thus for any immunizations covered under the state plan) only if they are parents of a dependent child on Medicaid or have a disability that qualifies them for supplemental income assistance when they become eligible for Medicaid. Burden on Public-Sector Programs The experience in Michigan and Detroit illustrates the continuing demand for immunization services from health department clinics, as either a primary or safety net source for such services. Although this evidence of the public’s trust in these clinics was welcome, health department clinics generally have limited resources and lack infrastructure for coordinating their services with other immunization providers or for seek-ing reimbursement from health plans for services covered under Medicaid capitation rates or VFC. The assessment of immunization status, in particular, can be time consuming and burdensome, requiring technical training and routine access to high-risk groups as well as provider records in a variety of health care settings. When other public programs are asked to establish links to immunization services, they expect compensation for the personnel time involved in making such assessments. For example, conducting immunization assessments through the Women, Infants, and Children (WIC) nutrition program has been an effective way to improve immunization rates in some communities. But without additional funding to support the required staff time and training, immunization assessments can divert limited WIC resources from the program’s primary tasks. SUSTAINING AND IMPROVING COVERAGE LEVELS The workshop discussions related to sustaining and improving immunization coverage levels emphasized that most states have not achieved

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop the national target of 90 percent coverage for 2 year olds and for older adults (see Table 2). Participants expressed concern that state and city averages mask “pockets of need,” where coverage rates are substantially and persistently low. In addition, the challenges in improving immunization coverage for adults were contrasted with those related to children’s immunization. Pockets of Need Many cities have neighborhoods that may be at increased risk for underimmunization and for outbreaks of vaccine-preventable diseases because of chronic poverty and other markers of lower socioeconomic status, which are often associated with lower immunization rates for children. A CDC study in June 2000 in the Englewood District of Chicago, a neighborhood in which 42 percent of households had an income of less than $10,000, found that measles vaccination rates were somewhat lower there than for Chicago as a whole (Rosenthal et al., 2001). Factors associated with higher levels of coverage included parents being able to provide the child’s immunization record during the study interview, starting a child’s immunizations on time, and obtaining immunization services from a public-sector provider. Only 18 percent of parents reported any barriers to obtaining immunization services, and they frequently cited long waiting times as a common barrier. Julie Morita from the Chicago Department of Health described the department’s response to the Englewood study, highlighting efforts to inform the community and local health care providers about the study results. These discussions focused on identifying both short- and long-term steps intended to improve immunization coverage. The availability of specific data about gaps in neighborhood coverage rates was cited as a key factor in engaging both health care providers and the community in these efforts. The short-term actions included locating children in need of immunizations, following up with reminder notices and household visits, and offering additional immunization services in the neighborhood. Longer-term activities are directed toward the community and toward providers. The community efforts, which are being led by the Englewood District Health Council, include promoting on-time vaccination for all children and establishing a program to track immunizations for babies born at a local hospital. The health department’s provider-based interventions include a reminder-recall system and home visits to children who do not respond to those notices. The health department will also ensure that providers have vaccine for VFC-eligible children. In addition, providers will receive feedback from health department assessments of the immunization status of children in their practices and guidance on strate-

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop gies to improve immunization coverage. A follow-up survey, planned for 2002, will assess the effectiveness of these interventions. Adult Immunization In contrast to the multiple programs designed to improve pediatric immunization rates, relatively few systematic efforts exist to address low adult immunization levels. In addition to the limited use of Section 317 funds to purchase vaccine for adults and the limited insurance coverage for adult immunization (noted above), the workshop discussions pointed to other factors that contribute to undesirably low rates of adult immunization. For example, adults often receive care from a variety of specialists (e.g., cardiologists, obstetricians-gynecologists) who may not attend to primary care concerns and who are generally less familiar with immunization issues and vaccine recommendations than are pediatricians and others who care for children. Some providers may lack adequate information about the seriousness of vaccine-preventable diseases in adults and the efficacy of the vaccines. The education of physicians and others who care for adults about the value of immunization is important because appropriate advice from health care providers improves immunization rates. Also highlighted was the growing contribution to adult immunization of services offered at nontraditional sites, such as pharmacies, super-markets, and workplaces. CONDUCTING SURVEILLANCE OF IMMUNIZATION COVERAGE AND VACCINE SAFETY Many of the workshop presentations emphasized the importance of surveillance programs as an important part of efforts to improve immunization rates, but such programs require adequate resources for imple-mentation and ongoing support. The Englewood study in Chicago, for example, demonstrated the value of having highly specific local data to identify problems and to stimulate a response. The city now needs ways to identify other neighborhoods with low immunization rates. The CDC survey conducted in the Englewood District is too expensive and labor intensive for routine use, so clinic assessments or reviews of immunization histories in school records or selected private practices may be more practical approaches unless training local interviewers can be demonstrated as a feasible alternative. Immunization registries have the potential to provide local data without requiring special surveys, but they require extensive collaboration between public and private health care sectors to implement and sustain the exchange of immunization data within a designated community. If

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop registries are up-to-date, they can help maintain accurate immunization records for children who receive care from multiple sources. But the work-shop discussions made it clear that while the registries in Michigan and Illinois are progressing, they are not yet complete enough to be used for surveillance. Some children are not included and many providers, especially those in the private sector, are not submitting reports. Workshop participants noted that even when health plans agree to provide data, they may not have the tools to monitor or enforce submission of reports by individual providers. Michigan’s experience has also shown that the cost of operating a registry remains high beyond the start-up period. IMMUNIZATION FINANCE POLICIES AND PRACTICES Some of the concerns related to immunization finance—increasing vaccine costs and insurance benefits, for example—have already been reviewed. In addition, workshop participants expressed concern about the stability of state funding for immunization programs. Term limits are increasing the influx of new state legislators and legislative staff who may be unfamiliar with the potential seriousness of vaccine-preventable diseases and the complexities of health care finance. The importance of maintaining an effective immunization infrastructure and adequate supplies of vaccine can easily be overlooked when immunization rates are high and disease prevalence is low. There is also concern that growing attention to claims of potential risks from vaccine use may weaken legislative support for immunization programs. Various financial disincentives were also noted. For individual providers, such disincentives result from the paperwork and delays in reimbursement as well as inadequate reimbursement for vaccine and vaccine administration. Financial disincentives can also arise from the administrative burden of programs such as VFC, which requires separate record-keeping for VFC and non-VFC vaccine supplies and services. Similarly, if Medicaid capitation rates are judged too low, some private health plans may choose not to bid on or continue Medicaid contracts, potentially limiting and disrupting the availability of immunization services for Medicaid enrollees.