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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