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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