Provider Perspectives

Jane Siegel, a pediatrician from the University of Texas Southwestern Medical Center in Dallas, reviewed several concerns regarding immunization efforts in Texas and in the nation more generally. Immunization rates have not yet reached target levels of 90 percent, despite evidence that immunizations are a good investment in reducing health care costs from infectious diseases. For example, in Dallas County, inpatient care related to the measles outbreak in 1989 and 1990 generated about $3.2 million in charges. Immunization also offers a way to avoid the “distraction” of preventable disease, especially in light of current concerns about bioterrorism and other health threats. Dr. Siegel noted that coverage rates for recommended sets of vaccines (e.g., the 4:3:1 or 4:3:1:3 series) for preschool-age children often suffer because children do not receive the fourth dose of DTaP at the recommended time.

The successful introduction of a new vaccine requires actions by federal and state officials and by parents, health care providers, and insurers. Dr. Siegel sees improvements in the reduction of delays between an ACIP recommendation and official inclusion of a vaccine under VFC. Also, key professional groups (e.g., ACIP, the American Academy of Pediatrics, and the American Academy of Family Physicians) are collaborating to produce an annual harmonized immunization schedule that provides consistent guidance from all three organizations. In Dr. Siegel’s view, improvements are still needed to speed the negotiation of federal contracts for the purchase of new vaccines and, in Texas, to improve the allocation of state funds in anticipation of increased vaccine purchase obligations (as



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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop Provider Perspectives Jane Siegel, a pediatrician from the University of Texas Southwestern Medical Center in Dallas, reviewed several concerns regarding immunization efforts in Texas and in the nation more generally. Immunization rates have not yet reached target levels of 90 percent, despite evidence that immunizations are a good investment in reducing health care costs from infectious diseases. For example, in Dallas County, inpatient care related to the measles outbreak in 1989 and 1990 generated about $3.2 million in charges. Immunization also offers a way to avoid the “distraction” of preventable disease, especially in light of current concerns about bioterrorism and other health threats. Dr. Siegel noted that coverage rates for recommended sets of vaccines (e.g., the 4:3:1 or 4:3:1:3 series) for preschool-age children often suffer because children do not receive the fourth dose of DTaP at the recommended time. The successful introduction of a new vaccine requires actions by federal and state officials and by parents, health care providers, and insurers. Dr. Siegel sees improvements in the reduction of delays between an ACIP recommendation and official inclusion of a vaccine under VFC. Also, key professional groups (e.g., ACIP, the American Academy of Pediatrics, and the American Academy of Family Physicians) are collaborating to produce an annual harmonized immunization schedule that provides consistent guidance from all three organizations. In Dr. Siegel’s view, improvements are still needed to speed the negotiation of federal contracts for the purchase of new vaccines and, in Texas, to improve the allocation of state funds in anticipation of increased vaccine purchase obligations (as

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop with the pneumococcal conjugate vaccine). Insurance plans also can be slow to add coverage for new vaccines. Dr. Siegel commented that fear or skepticism may slow acceptance of a new vaccine. In Dallas, for example, providers found that they had to counter inaccurate information in the media about the new pediatric pneumococcal vaccine. In addition, recent shortages of both older and new vaccines have been a reminder of the critical role of vaccine manufacturers in the success of immunization programs. VFC offers opportunities to strengthen a public-private partnership in support of immunization efforts in Texas. Dr. Siegel encouraged efforts to increase provider participation in the program. At present, about 60 percent of the private providers in the El Paso area participate in VFC, but only about 20 to 30 percent of the private providers in Dallas, Houston, and San Antonio (Bexar County) participate in the program (Figure 5). With a strong base of immunization providers in the private sector participating in VFC, the health department could devote additional resources to provider education on topics such as vaccine handling and storage, immunization assessments and reminder/recall systems, and vaccine safety concerns. The barriers to participation in VFC identified by Dr. Siegel include a lack of knowledge about the program, concerns about the administrative burden, a lack of access to certain combination vaccine products, lower reimbursement rates, and concerns over raising patient expectations for other free services. FIGURE 5 Providera participation in Texas VFC, by county, October 2000–September 2001. aProviders are licensed MDs that are designated family practice, general practice, pediatrics, or internal medicine.

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop Texas faces challenges in its efforts to implement evidence-based strategies to improve and sustain immunization rates. For example, problems in staffing and training led the Dallas health department to discontinue its immunization activities through WIC. Also, health departments have limited resources to devote to assessments of immunization coverage in provider practices under the AFIX program. The immunization registries have great potential as a tool for improving immunization coverage rates and reducing the levels of overimmunization, but the usefulness of the Texas registry is reduced by the opt-in provision that results in the omission of children and by restricted access that prevents some immunization providers from checking immunization records or recording the immunizations that they have provided. Dr. Siegel suggested, however, that concerns about bioterrorism might add weight to efforts to modify the registry to improve its usefulness for monitoring immunizations and other health interventions for all children. There may also be a role for registries in addressing emergency preparedness, provided such registries are fully functional, can track mass vaccination campaigns, monitor potential adverse effects, and facilitate the delivery of vaccines that need to be administered under emergency conditions. POTENTIAL FOR GREATER IMMUNIZATION BENEFITS FOR ADULTS In discussions of immunization issues, attention often focuses on the youngest children and the delivery of the array of vaccines in the childhood immunization schedule. W. Paul Glezen, of the Baylor College of Medicine in Houston, focused instead on potential gains from improved rates of immunization against influenza, especially in high-risk adult populations. He also commented on the broader public health benefits that would result from a strong infrastructure for immunization programs. Influenza remains an important source of vaccine-preventable illness and death, especially among elderly individuals (aged 65 and over). However, the disease also poses a risk for younger adults and children. Dr. Glezen noted that rates of hospitalization for influenza for children under age 5 are similar to those for the elderly population. Studies have shown that immunization against influenza not only reduces the incidence and severity of the disease but also saves money by reducing health care costs and lowering the amount of time lost from work (Nichol et al., 1994, 1995, 1999). Official recommendations call for annual immunizations against influenza for high-risk children and younger adults, such as persons with chronic illnesses or pregnant women, but coverage rates are low. To help

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop improve coverage rates, Dr. Glezen encouraged efforts to educate medical specialists about immunization recommendations and to develop immunization practice guidelines. Obstetricians, for example, should be encouraged to immunize pregnant women who will be in their second or third trimester during the winter flu season. Immunization helps protect them against pneumonia, for which they have an increased risk, and produces maternal antibodies that help protect their infants. Dr. Glezen also noted other concerns for the immunization system. A dependable supply of vaccines is essential. Manufacturers face strict regulatory requirements, but recent reductions in funding affect the ability of the Food and Drug Administration to perform some of its regulatory functions. In addition, liability protections extend to manufacturers only for the officially recommended children’s vaccines. Expanding the scope of the vaccine injury compensation program might encourage production of additional vaccines. In addition, Dr. Glezen suggested the use of immunization registries to provide annual reminder notices for vaccinations against influenza for high-risk children. A registry system might have a role in the immunization of adults as well. Strengthening key elements of the immunization infrastructure—public health laboratories, disease surveillance systems, and vaccine distribution and delivery systems—for routine operation will have the added benefit of improving readiness at the national, state, and local levels to respond to the challenges of bioterrorism or pandemic influenza. PRACTICAL CHALLENGES FOR PRIVATE PROVIDERS Two pediatricians in private practice in Texas, Jane Rider from San Angelo and Dianna Burns from San Antonio, reviewed the financial and administrative challenges faced by private providers who deliver immunization services in Texas. Vaccine Purchase and Reimbursement VFC supplies providers with vaccines to be administered to some children, but Dr. Burns described the substantial financial liability that providers incur in purchasing vaccines to be administered to children covered by private insurance. To obtain vaccines at a lower cost per dose, providers must make commitments for bulk purchases. Dr. Burns cited a requirement for a minimum vaccine order of $5,000 to avoid additional fees. Some manufacturers also require purchase of more than one type of vaccine to obtain discounts, but this may mean having to purchase a vaccine at a higher price than that offered by another manufacturer. The large up-front cost of bulk purchases can create cash flow prob-

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop lems for the physician or a group practice. The cost of that vaccine is recovered only as family payments or insurance reimbursements are received for vaccine doses administered to children. Dr. Burns’s practice, for example, purchased 1,500 doses of pneumococcal conjugate vaccine at a cost of $88,000, but after 6 months the practice had recovered only $30,000 in payments for administering the vaccine. For new vaccines, Dr. Burns and Dr. Rider noted that insurance reimbursements could be delayed if insurers are slow to provide appropriate codes. For example, some insurance reimbursements for use of the pneumococcal conjugate vaccine have been too low because confusion with the older, less expensive pneumococcal polysacchride vaccine (usually administered to adults) has resulted in mistakes in the coding or processing of claims. Dr. Rider observed that even with full payment of authorized reimbursements from insurers or under VFC, those payments are often not adequate. Providers incur not only the costs for vaccine but also costs for other materials and activities associated with vaccination, including syringes and other supplies, vaccine storage and inventory management, maintenance of office records, billing, and submission of records to the immunization registry. In addition, providers participating in capitated health plans may find that they are obligated to provide newly recommended vaccines without any adjustment in payments until a new contract is negotiated. Confusion for Providers and Patients Dr. Rider and Dr. Burns also highlighted several areas of confusion that affect immunization services in Texas. In terms of vaccine purchase, providers are finding that shortages of vaccines such as DTaP and weekly changes in restrictions on its availability complicate efforts to meet manufacturers’ requirements for minimum vaccine orders and may result in higher vaccine prices as well. Combination vaccine products also add confusion to vaccine purchase and use. Only certain combination products are available through VFC, but providers may prefer to use other products for privately insured patients because of their lower cost or their inclusion in a purchasing agreement with a specific manufacturer. Under those circumstances, providers may have to choose whether to purchase some vaccines at higher prices or to manage stocks of additional vaccine products and to use immunization schedules that differ among their patients. General confusion regarding insurance coverage for immunization only increases as recommendations and requirements for vaccination change. Insurers may cover only certain vaccines and may be slow to add

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop coverage for newly recommended vaccines. As noted earlier in this report, Texas has adopted a first-dollar coverage law, but self-insured plans covered by federal ERISA laws are exempt from state regulation. Parents are often uncertain about the coverage provided by their insurance plan, and Dr. Burns and Dr. Rider agreed that it could be difficult to obtain accurate information even when insurers are contacted directly. In Texas, local variations in recommendations for vaccination against hepatitis A are a special problem. Eligibility for coverage of vaccination against hepatitis A under public-sector programs or private insurance may depend on where a child lives, and some providers serve a mixed population of eligible and ineligible children. Without accurate information, parents or providers can be left with an unanticipated cost. If immunizations are not covered, parents must be willing to pay providers directly or seek immunizations from another source, such as the local health department or a clinic qualified to provide services to underinsured individuals under VFC. At present, however, pneumococcal vaccine purchased by the state is not available to underinsured children. Administrative Burdens Providing immunization services adds administrative burdens—and therefore costs—to private practices. For example, vaccine supplies must be monitored regularly to ensure that proper temperatures are maintained. Separate accounting and ordering systems are required for publicly and privately purchased vaccines. Office staff must determine the immunization status of patients from a mix of personal, office, and registry records, any of which may be incomplete. Getting information from other providers can be difficult because some providers are reluctant to fax immunization records over concern about privacy. Information must also be submitted to the state registry, a process that can require duplication of data entry for the office and the registry. Dr. Rider called for the development of electronic record systems that could facilitate transfer of information to the registry and eliminate the duplication of data entry. She also encouraged the design of electronic information systems that would improve the accuracy of the assessment of immunization status. She believed that greater consistency in coding conventions for vaccines and other data elements would be helpful. Other Considerations Problems of overimmunization and mistimed immunization were also noted. Giving children vaccines they do not need is neither good

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop health care nor an effective or appropriate use of limited resources. Several speakers observed that all immunization providers should be able to monitor registry records and should be encouraged to do so to avoid unnecessary immunizations. Efforts to educate parents about immunization should address the appropriate timing of immunizations as well as the number. In addition, the emphasis on meeting immunization goals should not contribute to the fragmentation or neglect of provision of other primary care for young children. Dr. Burns suggested that responsibility for staff and professional training and patient education might be a shared undertaking of providers, health departments, communities, and other organizations, such as the Texas Medical Association. Dr. Burns proposed consideration of universal vaccine purchase as a way to create a more seamless immunization system in Texas. Such a system may have the potential to alleviate problems such as confusion over insurance coverage and vaccine-related financial burdens for private providers. It might be possible to develop a public-private collaboration to fund universal purchase by involving insurers and health plans, which already have obligations to provide vaccines or cover vaccine costs. Dr. Freed noted that the recent adoption of universal purchase in North Carolina was associated with increased immunization coverage rates, but these efforts are expensive. The increased cost of vaccines may threaten the continuation of such programs in some states.