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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