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Private-Seetor Roles in the National Immunization Partnership -he pace of transformation has occurred at different rates within dif- ferent sectors of the national immunization system and individual states. In the March 2002 workshop, several speakers addressed the emerging roles played by private providers, health plans, and the busi- ness sector within the public and private partnership that now guides immunization efforts. These speakers included Samuel Katz, department of pediatrics, Duke University; David Tayloe, community pediatrician in private practice in Goldsboro, North Carolina; Carol Wilhoit, director of quality improvement for Blue Cross Blue Shield of Illinois; John Fontanesi, Community Health Pediatrics Department, University of California at San Diego; and Suzanne Mercure, National Business Coalition on Health. IMMUNIZATION AND PEDIATRIC PRACTICE Samuel Katz observed that although Congress has articulated a clear role for the federal government in facilitating the distribution of vaccines and sharing support for delivering immunization services to safety net populations, there is great ambiguity about the extent to which the fed- eral government should finance state and local infrastructure programs and public- and private-sector collaboration efforts. The contribution of individual components such as data collection, community outreach, reg- istries, program coordination, documentation and communication of "best practices," and other types of programmatic efforts to the achievement of 25

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26 SETTING THE COURSE national immunization goals needs to be demonstrated in legislative set- tings if these initiatives are to obtain broad support. This challenge is a difficult task that is often neglected during budgetary debates, when pub- lic health programs must compete with other worthy causes at the na- tional and state levels. David Tayloe described several significant changes in immunization practices within his rural practice over the past 25 years. In the period from 1977 to 1994, more than 50 percent of children in the state of North Carolina received their vaccines in public health clinics. The delivery sys- tem changed after 1994 because of the establishment of the Vaccines for Children program and the universal childhood vaccine distribution pro- gram in North Carolina. Today only 20 percent of the child population goes to the public health sector for vaccines. Higher immunization rates also occurred during this period of change. In the earlier period (1994), 60 percent of children were up to date with immunization. Today, North Carolina leads the nation in the percentage of 2 year olds who are fully immunized (about 88 percent). Dr. Tayloe described the increasing complexity of the vaccine sched- ule, which is particularly striking. In 1977, six shots (involving three dif- ferent vaccines) and four doses of oral vaccines were required to comply with recommended immunization standards. In 2002, 23 shots of 8 differ- ent vaccines were required. In earlier years, the vaccine name and date of administration could be written into the individual child's medical record and the parents' shot record. Now, the medical record requires more extensive documentation, including the vaccine name, date of adminis- tration, and lot number. In addition, information must be recorded not only in medical and parental records, but also posted on the state vaccine log to justify the next shipment of vaccines from the state vaccine pro- gram. Furthermore, vaccine storage is now more complicated, requiring compliance with detailed regulations, separation of public and private vaccine stocks, and an emergency plan. In 1977, local physicians did not have to think about liability preven- tion. Today, Dr. Tayloe indicated, they are expected to provide vaccine information statements to each patient and to obtain parental signature prior to administering each vaccine. The provider is expected to describe all possible risks and complications to parents and explain the need to report unusual symptoms to the Vaccine Adverse Events Reporting System. Other more recent changes have also occurred in the methods by which providers obtain vaccines and are reimbursed for immunization fees. Before 1994, Dr. Tayloe observed, Medicaid expected providers to give vaccines during well-child visits and bill the state program for the cost of the vaccines. Private patients paid cash for vaccines because insur-

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PRIVATE-SECTOR ROLES IN THE NATIONAL IMMUNIZATION PARTNERSHIP 27 ance coverage was rare, or went to the public health department for free vaccines. Today, quality standards such as the Health Plan Employer Data and Information Set (HEDIS) measures have created incentives for many health plans to offer immunization benefits. The public program has changed as well. The state of North Carolina (a universal purchase state) buys all vaccines and sends them to providers. Providers are then responsible for billing private insurers or Medicaid for the vaccine admin- istration fee. Dr. Tayloe described how the medical home concept is implemented within his own practice, which serves approximately 400 children daily in four offices in rural parts of North Carolina. The main office is open until 10 PM on weeknights and also provides services on weekend days. Pro- viders try to immunize every child who enters any office, but they fre- quently encounter barriers related to family education, antivaccine rheto- ric, cultural diversity, reimbursement practices, local public health bureaucracy, shortages in the vaccine supply, and complacency associ- ated with the lack of parental experience with vaccine-preventable infec- tious diseases. He indicated that his practice reports an average of one case of pertussis annually, usually involving infants who have received only one dose of DTaP. During the 15 years before the availability of vaccine for haemophilus influenza type B. the community also experienced 10 to 20 cases of meningitis/epiglottitis/sepsis that resulted in one death and one child with severe deafness. John Fontanesi reviewed findings from a study of workflow and time/motion observations of immunization practices in 10 community clinics and 5 private primary care practices (Fontanesi et al., 2000;2001~. Researchers in the San Diego study developed an observational checklist of patient encounters that describes operational conditions that affect the cost and likelihood of immunization. By studying the operational or envi- ronmental conditions that affect immunization practices, they sought to identify factors that could explain missed opportunities and to compare the impact of these factors with those of provider characteristics, atti- tudes, and beliefs. Dr. Fontanesi indicated that this type of study of im- munization practices could serve as a proxy for other primary preventa- tive care services. Dr. Fontanesi presented a systems mapping of clinic stages to de- scribe the operational environment of a busy pediatric practice. Research studies suggest that the amount of time available for direct patient/pro- vider contact during a well-child exam has gradually increased from 10 minutes in 1978 (O'Bannon et al., 1978) to 20 minutes in the late l990s (Fontanesi et al., 2000~. Within this encounter period, the time associated with administering a vaccine (3.5 minutes) has remained relatively con- stant. Multiplying this time by the number of live births and injections

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28 SETTING THE COURSE that are required as part of the 4:3:1:3 schedule produces a total of 32.3 million person-hours to immunize all U.S. children. Dr. Fontanesi commented that missed opportunities for immuniza- tion frequently occur because providers do not have physical access to a patient's immunization record in a timely manner when the patient is receiving clinical care. Health care providers are frequently overburdened with limited time and redundant administrative forms that diminish their ability to assess the immunization needs of their patients or to remind their patients of the need for follow-up visits when the administration of vaccines requires multiple visits. As examples, he noted that more than 200 clinical practice guidelines have been published for primary care pre- vention for O to 2 year olds. Nine clinics interviewed in the San Diego study provided 200 separate forms to be used for children under age 35 months. Their data indicated that fewer than 85 percent of immunizations administered were ever documented, often because of the administrative burden to nonclinical staff. Dr. Fontanesi suggested that the data associ- ated with multiple recordkeeping forms, often required as part of differ- ent access, documentation, and quality assurance policies that are in- tended to protect the consumer, may actually interfere with care as currently executed. The reduction in redundant forms, audits, and other activities could release critical time resources that could then be allocated to more productive efforts. He noted that quality should be viewed as an investment that requires a consistent and comprehensive approach in building capacity to be effective. Improving immunization rates and other quality-of-care practices will require reductions in the variability now associated with clinical practice. The time allotted for immunizations competes with nonimmunization time needs that might be more pressing. Immunization appears to lengthen waiting room times by 2 minutes and extends total clinic time by the same proportion. Despite these challenges, opportunities exist to improve record- keeping and vaccine administration practices. For example, Dr. Fontanesi observed that patients spend substantial time in examining rooms that might be directed toward immunization efforts (27 percent room time with provider; 73 percent room time without provider). HEALTH PLAN INCENTIVES FOR PROVIDERS Carol Wilhoit from Blue Cross Blue Shield of Illinois (BCBSIL) de- scribed collaborative practices between health care plans and clinicians to improve childhood and adult immunization rates. As large private com- mercial products of BCBSIL, HMO Illinois and Blue Advantage HMO enroll more than 900,000 members and contract with approximately 90

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PRIVATE-SECTOR ROLES IN THE NATIONAL IMMUNIZATION PARTNERSHIP 29 medical groups (MGs) and independent provider associations (IPAs). The health maintenance organization (HMO) pays MGs/IPAs (not individual providers) on a capitated basis. The compensation package includes a quality improvement (QI) fund that allocates part of the compensation package as an incentive for improving quality of care. The HMOs met with representatives from the medical groups and IPAs in 1996 to discuss collaborative approaches to QI. Within this collaboration, the HMO performs certain roles (such as developing project criteria, identifying target populations, selecting ran- dom samples, and performing and reporting data analysis). The MGs/ IPAs also perform certain activities, including the review of administra- tive and medical records, providing abstracted data and supporting docu- mentation, and developing and implementing interventions (such as flowsheets, medical record stickers, postcards, and so forth) that may be recommended by the HMO or developed locally. The HMO has rewarded performance using two approaches: payment for participation and pay- ment based on the level of performance. Using the example of influenza vaccination, Dr. Wilhoit illustrated how the HMOs sought to change practice with respect to vulnerable popu- lations, particularly asthmatics, diabetics, and members age 65 and older. In the first stage, the plan encouraged each MG/IPA to document data and submit records to the HMO for reporting of MG/IPA-specific rates, for which the groups received payments from the QI fund. Payments ranged up to six figures, depending on the size of the group. Baseline rates for the targeted population were 21.8 percent (1996), 22.7 percent (1997), and 22.8 percent (1998~. Beginning in 2000, the HMOs shifted the quality fund payment to reward performance (the 1999 MG/IPA flu shot rate) instead of just program participation (i.e., providing medical record data). The flu shot rate for the HMO network increased and rates also improved substantially for many MGs/IPAs. For example, Dr. Wilhoit observed that 4 groups had achieved more than 40 percent coverage rates for the targeted population in 1998; by 2000, 12 groups had reached this level of coverage. Similarly, three groups had achieved 35 to 40 percent coverage rates in 1998; nine groups were performing at this level in 2000. The number of groups performing at the very low end also declined: 70 groups had achieved rates below 20 percent coverage in 1998. By 2000, only 30 participating groups fell within this category. Rewarding perfor- mance led to higher flu shot rates. In a second example, Dr. Wilhoit described how the HMOs sought to evaluate the impact of those providers who explained the importance of vaccination to their high-risk patients. A 1997 member survey indicated that the influenza immunization rates for high-risk members whose phy- sician explained the importance of a flu shot was 79 percent, compared

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30 SETTING THE COURSE with a 19 percent rate for patients to whom the "importance" message was not presented by the physician. Since 1998, BCBSIL has distributed preventive care and diabetes flowsheets to its physicians. The flowsheets also appear to increase influenza immunization rates within the diabetic population (32 percent of diabetics with flowsheets in the BCBSIL HEDIS Comprehensive Diabetes Care sample for 2000 who had a diabetes flowsheet in the medical record had received an influenza vaccination, compared to 17 percent who did not have a flowsheet). Improving childhood vaccination rates is a more difficult challenge because of the complexity of the childhood immunization schedule and the uncertainties among both providers and parents as to whether chil- dren are up to date at specified times. In 1997, Dr. Wilhoit reported, BCBSIL sent surveys to parents of the 83 children in their 1996 HEDIS sample who did not meet criteria for the recommended vaccine series. Slightly more than half (57 percent) of the parents completed the survey. Of the respondents, 46 of 47 incorrectly thought their child had been fully immunized by age 2. Using these data, the HMOs convened focus groups with MGs/IPAs and parents of children under 2. In these discussions, parents indicated that they wanted their doctors to remind them about timely immunization because the schedule was too complex for them to monitor on their own, and the providers wanted to have lists of children who were not up to date and easy-to-use reminder cards that could be incorporated into their routine office practices. The use of immunization flowsheets has also led to improvements in adolescent immunization rates for hepatitis B and measles, mumps, and rubella 77 percent of adoles- cents with flowsheets had complete immunization compared with 11 per- cent who did not, according to 1999 data. Dr. Wilhoit indicated that BCBSIL had initiated a new quality im- provement project in collaboration with the departments of public health from Chicago Cook County and the state of Illinois. Under this new plan, at least 50 percent of the plan's pediatricians (and some family practice physicians) will participate in an assessment, feedback, and information exchange intervention, which will include information about immuniza- tion procedures and the current immunization rate of the practice. The MG/IPA will prepare a corrective action plan for each physician practice whose immunization rate is below 60 percent. In conclusion, Dr. Wilhoit observed that physician promotion of pre- ventive services is a key determinant of whether patients receive recom- mended services. Flowsheets are highly correlated with complete immu- nization, and additional compensation can motivate performance improvements as well. Immunization requirements for school attendance, and other public policy interventions, are strong influences on immuniza- tion rates at the population level.

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PRIVATE-SECTOR ROLES IN THE NATIONAL IMMUNIZATION PARTNERSHIP 31 Carey Vinson from the American Association of Health Plans com- mented that even though immunization levels are an important measure of quality in HEDIS assessments of private health plans, market forces are eroding the private sector's capacity to address public health goals. Some states, such as Pennsylvania, require managed care organizations to offer immunization benefits as a standard feature of health benefit plans. How- ever, the continuing additions of new and more expensive vaccines are creating more costs that the plans must absorb or pass on to their sub- scribers in the form of higher premiums, deductibles, or co-payments. He suggested that these increasing and often uncontrollable costs discourage some employers from offering immunization benefits and can lead to tradeoffs with other benefits that are more stable and less costly. BUSINESS-SECTOR ROLES Suzanne Mercure, project manager for the National Business Coali- tion on Health (NBCH), described the role of the business community in supporting immunization efforts and achieving national immunization goals as part of employee health benefit plans. NBCH represents 85 em- ployer coalitions, with outreach to 11,000 employers, 21 million employ- ees, and their dependents. The coalition supports community health re- form and seeks to improve the value of health care provided through employer-sponsored health plans by focusing on total cost (direct and indirect) and quality (clinical, service, and safety). The coalition has se- lected the topic of adult influenza vaccination for attention because of their view that this type of vaccination is an inadequately provided pre- ventive service that is simple to administer, appealing to employers, and consistent with the recommendations of the Community Prevention Task Force. NBCH works with multiple partners in a Cooperative Agreement with the Centers for Disease Control and Prevention (CDC) in three sites (Connecticut, southeastern Michigan, and Colorado) to test different in- terventions, such as the use of payroll insert letters for all employees, telephone call reminders from a high-risk member health plan, the devel- opment of a common data set, and an employer tool kit. The employer tool kit consists of several items: an information sheet that presents a "business case" for adult influenza immunization, infor- mation about local flu shot clinics for employees, worksite clinic planning guides, ideas for working with health plans, and consumer information campaign materials. Evaluations of the partners project are underway in two sites, Colo- rado and Connecticut. The Connecticut evaluation consisted of a member survey for year 2000 interventions. The survey data indicated that various reminder/outreach approaches for employees (phone, postcard, phone/

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32 SETTING THE COURSE post, and payroll inserts) had no discernible effect because nearly half the population already had been vaccinated prior to the intervention re- minder cards or calls. The maximum reminder effect may already have been achieved in the absence of the intervention effort. An evaluation of the Colorado intervention is now underway. fulianna Gonen, Ph.D., Director of the Center for Prevention and Health Services for the Washington Business Group on Health, provided an additional perspective about the role of the business sector in imple- menting efforts to help achieve national immunization goals. She noted that most large employers offer comprehensive health plans that include immunization benefits; some plans even include first-dollar coverage for some vaccines, which protects the employee from paying for immuniza- tion services through a deductible or co-payment. In addition, many em- ployers offer access to influenza vaccines at their worksite and educate their employees about the importance of immunization. Recent shortages of the influenza vaccine have affected these efforts, but this disruption may be only temporary. In fact, in some cases the shortages appear to increase interest in and demand for the influenza vaccine. Dr. Gonen indicated that employers turn to many different sources for information on coverage policy, including the CDC National Immu- nization Program, medical societies such as the American Academy of Pediatrics and the American Medical Association, individual health plans, and private consultants. There is increasing interest in identifying programs that demonstrate evidence of impact and contribute to im- provements in community immunization levels. Yet employers still need guidance, including access to "consumer-friendly" websites for employ- ees concerned about the value or safety of certain vaccines, and the de- velopment of toolkits to help them implement successful immunization programs. Given the significant annual increases in health care costs, Dr. Gonen observed that employers are developing strategies to help control or re- duce their health care expenses. Some employers are passing on increased costs to their employees in the form of higher deductibles or co-payments. Whether preventive services can be protected within these cost control strategies is uncertain without a clear business case as well as consumer- level information about their importance. Consumers who are given greater discretion over allocating their employer's health care contribu- tion may have little incentive to spend dollars on preventive services such as immunization compared with expenses that appear to have more im- mediate and tangible benefits, such as routine medical care or even cos- metic surgery.