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SET ING HOURSE A STRATEGIC VISION FOR IMMUNIZATION PART ~ SUMMARY OF THE WASHINGTON WORKSHOP , D.C Committee on the Immunization Finance Dissemination Workshops Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES ThE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu , ,

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi- neering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Centers for Disease Control and Prevention. The views presented in this report are those of the Institute of Medi- cine Committee on the Evaluation of Vaccine Purchase Financing in the United States and are not necessarily those of the funding agencies. International Standard Book Number 0-309-09068-7 (Book) International Standard Book Number 0-309-52735-X (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http:// www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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"I(nowin,g is not enough; we must apply. Willing is not enoa~,gh; we must do." Goethe ............................. - - . .. .. ::: : .: :: :: :: :: ... :: I..... INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating soci- ety of distinguished scholars engaged in scientific and engineering research, dedi- cated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem- bers, sharing with the National Academy of Sciences the responsibility for advis- ing the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal gov- ernment. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www. nationa l-academies.org

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COMMITTEE ON THE IMMUNIZATION FINANCE DISSEMINATION WORKSHOPS DAVID R. SMITH, M.D. (Chair), President, Texas Tech University Health Sciences Center, Lubbock, TX BRIAN BILKS, M.D., Professor and Chair, Department of Health Services Management and Policy, The George Washington University STEVE BLACK, M.D., Co-Director, Vaccine Study Center, Kaiser Permanente, Oakland, CA GORDON H. DeFRIESE, Ph.D., President and Chief Executive Officer, North Carolina Institute of Medicine, Woodcroft Professional Center, Durham DIANNE WHITE DELISI, M.A., State Representative, Texas House of Representatives R. GORDON DOUGLAS, OR., M.D., Former President, Merck Vaccines (retired), Princeton, Nr JONATHAN FIELDING, M.D., M.P.H., Director of Public Health and Health Officer, Los Angeles County Department of Health Services MAXINE HAYES, M.D., M.P.H., State Health Officer, Washington State Department of Health, Olympia ROBERT L. JOHNSON, M.D., Professor and Chair, Division of Adolescent and Young Adult Medicine, University of Medicine and Dentistry of New rersey-New Jersey Medical School SAMUEL L. KATZ, M.D., Wilburt C. Davison Professor Emeritus, Department of Pediatrics, Duke University Medical Center WILLIAM KISSICK, M.D., M.P.H., Dr.P.H., George Seckel Pepper Professor of Public Health, The Leonard Davis Institute, The Wharton School, Philadelphia RONALD I. SALDARINI, Ph.D., President, Wyeth Lederle Vaccines and Pediatrics (retired), New Jersey WILLIAM SCHAFFNER, M.D., Professor and Chairman, Department of Preventive Medicine, Vanderbilt University School of Medicine GARTH SPLINTER, M.D., M.B.A., Associate Professor, Chief Medical Officer, University Hospital Trust, Oklahoma City, OK Committee Staff Rosemary Chalk, Senior Program Officer Ryan Palugod, Senior Project Assistant v

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REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with pro- cedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its pub- lished report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Bernard Guyer, M.D., M.P.H., Chair, Department of Population and Family Health Sciences, Johns Hopkins University Bloomberg School of Public Health Sara Rosenbaum, I.D., Director, Center for Health Policy Research, School of Public Health and Health Services, The George Washington University Sandra Ross, Immunization Program Coordinator, Health and Hu- man Services Agency, San Diego, California lane E. Sisk, Ph.D., Professor, Department of Health Policy, Mount Sinai School of Medicine Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Neil Vanselow, M.D., Rio Verde, AZ. Appointed by the National Re- search Council, he was responsible for making certain that an indepen- dent examination of this report was carried out in accordance with insti- tutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. Al

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ACKNOWLEDGMENTS The Institute of Medicine (IOM) workshop on immunization finance was organized with the assistance of several health care organizations and health care providers throughout the metropolitan area of Washing- ton, DC, including the Association of State and Territorial Health Officialss, the American Academy of Pediatrics, the American Associa- tion of Health Plans, and the Washington Business Group on Health. Staff from the National Immunization Program of the Centers for Disease Control and Prevention (CDC) in Atlanta helped to identify immuniza- tion program directors and public health advisers who served as speakers and participants in the workshop. CDC officials also prepared data analy- ses and exhibits to inform the workshop discussions. The IOM workshop was audiocast on March 18, 2002. Electronic files of the speakers' presentations are available at the IOM website: www. iom.edu/iom/iomhome.nsf/Pages/Immunization+ Finance+dc+agenda. . . V11

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contents EXECUTIVE SUMMARY INTRODUCTION A NATIONAL PERSPECTIVE ON THE IMMUNIZATION SYSTEM The National Immunization Partnership, 6 The Institute of Medicine Study, 9 Response from the Centers for Disease Control and Prevention, 11 BUILDING THE IMMUNIZATION INFRASTRUCTURE State Perspectives, 15 Local Perspectives, 19 National Survey of State-Level Immun Programs, and Practices, 20 Case Study Findings, 23 PRIVATE-SECTOR ROLES IN THE NATIONAL IMMUNIZATION PARTNERSHIP Immunization and Pediatric Practice, 25 Health Plan Incentives for Providers, 28 Business-Sector Roles, 31 1 ~ 1 3 6 15 ization Policies, 25

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x UNRESOLVED PROBLEMS AND FUTURE CHALLENGES Increasing Vaccine Costs, 33 Changing Partnerships, 33 Immunization and Health Security, 34 Simplifying the Immunization System, 34 Stable Funding, 35 FINAL OBSERVATIONS REFERENCES APPENDIXES A Workshop Agenda B List of Workshop Participants C Website Referrals CONTENTS 33 36 38 41 44 47

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Tables, Figures, and BON TABLES 1 Vaccines in Widespread Use, 1985-2020, 10-11 2 Vaccine Supply Policy, January 2000, 21 FIGURES 1 Changes in the childhood vaccine schedule, 1975-2000, 8 2 Six roles of the national immunization system, 12 3 Measles incidence per 100,000 population compared to available federal grant funds ($ in millions), California, 1988-2000, 18 BOX 1 TOM Recommendations, Calling the Shots, 13

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