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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