Strategies for Achieving Immunization Goals

Many of the workshop presentations focused on problems for immunization programs nationally and at the state and local levels. Concerns about the inadequacy of existing efforts received extensive attention. However, participants also described efforts to address some of these problems and highlighted four strategic approaches:

  • quality improvement measures within health plans,

  • performance-based contracting for Medicaid managed care services,

  • public policy actions, and

  • public-private partnerships.

QUALITY IMPROVEMENT MEASURES IN HEALTH PLANS

Better information systems and practice tools help physicians ensure that patients receive appropriate preventive services, including immunizations. Achieving high levels of immunization coverage has emerged as a key measure of quality in assessing the performance of both health care plans and providers. As part of a collaborative quality improvement initiative for its HMO plan, Blue Cross Blue Shield of Illinois (BCBSIL) began working in the mid-1990s with participating physician groups on two immunization efforts: (1) to improve influenza immunization rates for asthmatic and diabetic adults and for all adults age 65 and over and (2) to improve immunization rates for 2 year olds as measured in HEDIS surveys. Through its own analysis, BCBSIL determined that both adult



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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop Strategies for Achieving Immunization Goals Many of the workshop presentations focused on problems for immunization programs nationally and at the state and local levels. Concerns about the inadequacy of existing efforts received extensive attention. However, participants also described efforts to address some of these problems and highlighted four strategic approaches: quality improvement measures within health plans, performance-based contracting for Medicaid managed care services, public policy actions, and public-private partnerships. QUALITY IMPROVEMENT MEASURES IN HEALTH PLANS Better information systems and practice tools help physicians ensure that patients receive appropriate preventive services, including immunizations. Achieving high levels of immunization coverage has emerged as a key measure of quality in assessing the performance of both health care plans and providers. As part of a collaborative quality improvement initiative for its HMO plan, Blue Cross Blue Shield of Illinois (BCBSIL) began working in the mid-1990s with participating physician groups on two immunization efforts: (1) to improve influenza immunization rates for asthmatic and diabetic adults and for all adults age 65 and over and (2) to improve immunization rates for 2 year olds as measured in HEDIS surveys. Through its own analysis, BCBSIL determined that both adult

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop patients and parents relied on physicians for guidance on immunizations and that the physicians wanted assistance in monitoring the immunization needs of their patients. Carol Wilhoit from BCBSIL described how the health plan assumed responsibility for providing detailed instructions or “flowsheets” to guide care for specific patient populations, for collecting and analyzing data on immunization coverage, and for reporting the results of those analyses to the physician groups. Data for 2000 show that the use of flowsheets was associated with higher immunization rates for both children and adults. (However, even with the flowsheets, only 32 percent of adults with diabetes received an influenza vaccination.) PERFORMANCE-BASED CONTRACTING Performance-based contracting provides an opportunity to use legal and economic tools to promote achievement of higher immunization coverage rates and other public health goals. In principle, both the public sector and the private sector (through health plans offered by employers) could use this approach. The experience of Michigan’s Medicaid managed care contracts was discussed in the workshop as one example of management by performance. These contracts require participating plans to provide all ACIP-recommended vaccines, to use vaccine available through VFC, to provide immunization in conjunction with Medicaid’s provisions for well-child care, to participate in the state’s immunization registry, and to reimburse health departments for immunizations provided to a health plan’s enrollees. In addition, the contracts include financial penalties for noncompliance. But it was acknowledged that such contracts are not without problems, many of which are related to the challenges discussed by others at the workshop. For example, a health plan may incur a substantial financial liability for coverage of all ACIP-recommended vaccines if the cost of a new vaccine has not been factored into capitation rates and the vaccine is not yet available through a federal contract or VFC. Health plans may not receive enough information from individual providers, or may not have suitable information systems, to be able to monitor whether children are receiving immunizations at appropriate times. Similarly, state health departments may lack the infrastructure to seek reimbursements from health plans for immunization services to enrollees or to monitor health plan performance in order to apply sanctions or rewards. And the costs of monitoring need to be considered against the benefits that such services are designed to achieve. However, some health plans have already demonstrated the feasibil-ity of using performance-based strategies to improve immunization cov-

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop erage rates. For example, BCBSIL established a quality improvement fund that provided payments to providers on the basis of performance-based criteria. For the first three years of each project, the performance criteria were based on submission of the data and documentation needed to assess immunization rates. These data were not otherwise available, and the quality improvement payments provided an incentive for physician groups to improve the quality of their immunization records. With the establishment of data submission practices, the performance criteria for quality improvement payments changed and are now based on the immunization rates achieved by the participating physician groups. Prelimi-nary results suggest that immunization rates have increased under the new payment criteria. PUBLIC POLICY ACTIONS In addition to financial support and regulatory roles, public policy actions can stimulate immunization performance through the creation of universal “checkpoints.” It is widely recognized, for example, that school entry requirements have ensured that nearly all children are completely immunized by the time they reach age 5 or 6. The addition of MMR and hepatitis B vaccination to school requirements for adolescents in some states appears to be the principal factor driving up coverage rates for those vaccines. BCBSIL found that while its quality improvement program was achieving modest improvements in adult and preschool immunization rates, the immunization rates for adolescents rose from 17.5 percent in 1998 to 59.6 percent in 2000 without any intervention by the health plan. The lack of comparable checkpoints was cited as one factor contributing to the persistence of low immunization rates among adults. Workshop participants suggested exploring opportunities to use public policy tools of this sort to improve immunization rates for adults (e.g., immunization requirements for nursing home residents). Other opportunities to use public policy tools may also exist. For example, states or the federal government could mandate that Medicaid or VCF providers participate in state immunization registries. But such requirements must be considered carefully to ensure that they do not impose unreasonable burdens on providers and do not have the adverse effect of reducing the number of providers willing to participate in Medicaid or VCF. PUBLIC-PRIVATE PARTNERSHIPS Many of the workshop participants indicated that public-private partnerships are an important strategy for improving immunization rates for

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop children and adults. Some of the examples that were discussed took the form of relatively formal activities, but other, less-formal types of partnerships were also considered. The response to the study of the Englewood District in Chicago illustrated the recent emergence of a neighborhood partnership in response to concerns about low immunization rates. With data from the CDC study, the city health department was able to begin working with health care providers, parents, community agencies, and the local health council. Many of the longer-term activities are now sustained under the leadership of the health council. The measles outbreak of the early 1990s also stimulated the development of Chicago-area partnerships that have evolved into the broadly based Chicago Area Immunization Campaign and Chicago Partnership for Public Health. These citywide activities convene collaborators from government, health plans, professional organizations, local businesses, community organizations, and philanthropic groups. Partnership efforts provide an opportunity to educate the broad range of participants about immunization concerns and about how they can respond to those concerns. Business leaders, for example, can learn how their health insurance benefits packages affect the costs of immunization for their employees. And philanthropic groups can identify opportunities to support community education or quality improvement programs by health care providers’ professional organizations. The health department also continues to work directly with providers to conduct immunization assessments in their practices, but officials noted that they have only three staff members for a population of 1,200 VFC providers. The Partners Project is a national partnership that seeks to develop science-based approaches to improve the delivery of preventive services, including adult immunization. A project team based in southeast Michigan has participants from the region’s major health plans, major automobile manufacturers and the United Auto Workers (purchasers of health plan services), the state and local health departments, and a local provider organization. For this project, factors that contributed to the success of the work of the partnership included a clear alignment of goals, the involve-ment of leadership from the partner organizations, skilled assistance to resolve conflicts, achievable short- and long-term outcomes, persistence and patience, confidentiality, and trust. The workshop discussions also pointed to the importance of building new partnerships within the health care community. Professional societies have a role to play in keeping their members informed about immunization issues and in establishing expectations for appropriate standards of practice. Professional schools have a responsibility to provide up-to-date training for new clinicians and also have the opportunity to bring immu-

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Setting the Course: A Strategic Vision for Immunization Finance - Part 1 Summary of the Chicago Workshop nization expertise and other resources to the communities in which they operate. Professional schools and professional societies can also help reach out to new partners in immunization, such as pharmacists and medical specialists.