Health Plans and Employers

Health plans and employers play a major role in shaping the financial environment for the delivery of immunization services. For the private sector, decisions by health plans and employers together help determine the cost and scope of coverage available to employees. Increasingly, publicly funded health services under Medicaid and similar programs are also delivered through private health plans rather than through health department clinics.

HEALTH PLAN PERSPECTIVES

Maurine Porto, medical director for Community First Health Plans, a not-for-profit health maintenance organization (HMO) in San Antonio, discussed the immunization issues affecting health plans. Community First Health Plans has members who are enrolled in the Medicaid program and the State Children’s Health Insurance Program (SCHIP) as well as commercially insured members, most of whom work for the county government or small employers.

Serving Medicaid members, whose eligibility for the program frequently changes, poses special challenges. The rapid turnover in the Medicaid population (100 percent in 12 months in Dr. Porto’s HMO) has a negative effect on the continuity of care for the individual and makes it difficult to get a meaningful measure of the immunization coverage rates among children or of the quality of the immunization services provided by the health plan. If children are not enrolled in a managed care plan for



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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop Health Plans and Employers Health plans and employers play a major role in shaping the financial environment for the delivery of immunization services. For the private sector, decisions by health plans and employers together help determine the cost and scope of coverage available to employees. Increasingly, publicly funded health services under Medicaid and similar programs are also delivered through private health plans rather than through health department clinics. HEALTH PLAN PERSPECTIVES Maurine Porto, medical director for Community First Health Plans, a not-for-profit health maintenance organization (HMO) in San Antonio, discussed the immunization issues affecting health plans. Community First Health Plans has members who are enrolled in the Medicaid program and the State Children’s Health Insurance Program (SCHIP) as well as commercially insured members, most of whom work for the county government or small employers. Serving Medicaid members, whose eligibility for the program frequently changes, poses special challenges. The rapid turnover in the Medicaid population (100 percent in 12 months in Dr. Porto’s HMO) has a negative effect on the continuity of care for the individual and makes it difficult to get a meaningful measure of the immunization coverage rates among children or of the quality of the immunization services provided by the health plan. If children are not enrolled in a managed care plan for

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop at least 12 months, they do not meet the protocol for inclusion in the HEDIS measures that are commonly used to assess immunization coverage levels in private health plans. In contrast, children enrolled in SCHIP have continuous eligibility for a year, improving the chances that a single health plan can influence immunization coverage levels. Dr. Porto noted that although Medicaid contracts include monetary incentives for health plans that achieve specified immunization coverage levels, the payments are too small to have much influence on health plan activities. Health plans invest resources in both provider- and member-oriented immunization activities. Efforts are made to help providers manage their immunization records and to produce reminder notices. Financial incentives have been offered to encourage providers to improve immunization coverage rates, but the availability of funds for incentive payments depends on the overall financial performance of the health plan. Member education materials have targeted compliance with the immunization schedule and immunization against influenza for high-risk groups, such as people with asthma. Dr. Porto noted that health plans are keenly aware of immunization issues because under the HEDIS program they are required to report immunization rates among their members. She emphasized, however, that the HEDIS program was designed to monitor the quality of health plans and is not a substitute for the kind of population-based surveillance of immunization rates provided by NIS. Some health plans are willing to make some adjustments to achieve a better match between HEDIS and NIS measures, but HEDIS already requires a substantial investment for the collection and auditing of data. Dr. Porto suggested that it was not reasonable to expect health plans to collect additional data to try to approximate population-based surveillance. Improvements in the state immunization registry would be welcome. If registry records were more complete, health plans might find that their immunization rates in the HEDIS program would improve. Adoption of an opt-out approach would help increase the rate of completeness of reporting. Under the current opt-in system, a health plan cannot automatically submit immunization records because information on parental consent to include a child in the registry may not be available. Dr. Porto also urged greater coordination among the various agencies and organizations that periodically review health plan and provider records, as in the AFIX program, to assess immunization coverage rates in a provider’s practice. Repeated requests for record reviews such as these can be disruptive for providers and staff. Dr. Porto concluded with encouragement of support for a universal vaccine purchase program in Texas. She observed that the current system

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop of federal, state, and private vaccine purchase is complex for health plans as well as providers. HOW EMPLOYERS VIEW IMMUNIZATION COVERAGE In the United States, most private health insurance coverage is offered by employers. That means that decisions by employers about the benefits included in the health plans offered to employees determine immunization coverage for many children and adults. Lola Chriss, manager for total compensation and benefits for Texas Instruments, Inc., discussed the factors that influence employer decisions. Ms. Chriss began by emphasizing that the first priority for a company is preserving shareholder value and that decisions regarding health insurance and other employee benefits are frequently made in that context. Employers, such as Texas Instruments, that offer health plans under the provisions of ERISA are relatively free to set their own priorities about the range of services that they cover and the allocation of payment arrangements for those services. In terms of who should pay for immunization services, the options are employees, health plans, or the employer. Texas Instruments has chosen to purchase benefits packages in which the health plan provides first-dollar coverage for all eligible immunizations. Ms. Chriss observed that the cost of immunizations is small relative to the cost of other types of health care services covered by employer-based insurance plans and is not a barrier to coverage for most employers. However, the complexity of the immunization schedule is a more cumbersome feature; from an employer’s perspective, it often is not clear what immunization services should be covered by a benefit package. For example, certain immunizations are required for school entry, but others are recommended for younger children or certain adults. In the past, Texas Instruments has covered only the immunizations required for school entry. A decision was made to add coverage for the pneumococcal conjugate vaccine, an expensive vaccine that is not required for school entry, to eliminate the administrative burden created by coverage appeals. Ms. Chriss indicated that employers need better guidance from sources such as ACIP or the American Academy of Pediatrics to understand the significance of distinctions between recommended and required immunizations. They also need assistance in making decisions about coverage for immunizations for older children and adults. She observed that employers’ confusion about issues such as coverage for immunizations reflects a need for more dialogue among employers, health departments, and health care providers. As an example, she noted that as a result of discussions at the IOM workshop, Texas Instruments would consider ad-

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop ditional coverage for well-child care, which at present is limited to visits for immunizations. Other workshop participants echoed Ms. Chriss’s concerns about the confusion created by distinctions between recommended and required immunizations. They also agreed that greater clarity is needed in implementing immunization recommendations from ACIP and other professional groups. Dr. Rodewald, of the National Immunization Program at CDC, noted that the epidemiology of disease risks during childhood helps explain why some immunizations are recommended for infants but are not required for school entry. The risk for pneumococcal disease and Haemophilus influenzae type b, for example, is high for infants and very young children but not for school-age children. Insurance plans should cover the schedule of vaccines recommended by health care organizations rather than restricting their benefits only to those vaccines that are required for school entry. Dr. Stanley, of the Texas Department of Health, proposed that the state as well as employers separate immunization coverage decisions from the mandates for school entry.