State assessments should include determination of whether individual children are receiving appropriate immunizations on time and whether individual providers are giving the immunizations that their patients need. Both providers and public health authorities should monitor whether children have received immunizations and should follow-up with those who have not. States also must meet the needs of children who are eligible for but not enrolled in programs such as Medicaid and WIC. These children may lack a source of primary care that will provide immunizations and may the miss immunization services offered to children enrolled in such programs.

Workshop participants expressed particular concern about the impact of managed care programs on children receiving Medicaid benefits. In Los Angeles, for example, some of the HMOs enrolling inner-city families have few providers in those neighborhoods. A review of California 's Medicaid managed care program found that reimbursement rates were inadequate to allow providers to deliver good care or to remain financially viable and that there was insufficient oversight of the program by the state. The Florida Medicaid program has received permission to exclude immunizations from its Early and Periodic Screening, Diagnostic, and Testing (EPSDT) program and to require referrals to public clinics, which provide vaccines free of charge. The number of children who actually receive their immunizations after referral to a public clinic is not known.

States should work with providers to ensure that they have an accurate picture of the immunization services they are providing. Susan Lett reported that practice-based assessments in Massachusetts are showing many providers that they are immunizing a smaller proportion of children than they thought. The assessments are labor-intensive, and Lett and her staff now have more requests for assessments than they can conduct in a timely manner. They have found, however, that many private providers are unfamiliar with the capabilities of computer-based information systems and have little interest in office-based patient tracking systems, which would enable them to do their own assessments.

MEETING THE DEMAND FOR IMMUNIZATION SERVICES

Expectations that states, communities, providers, or parents will be held accountable for properly immunizing children must consider whether resources are available to provide those services. Workshop participants observed that often they are not. States have reported that they need funds to support additional staff, education and outreach activities, and infrastructure development if they are to achieve 90 percent immunization rates (ASTHO, 1992). Fewer than 60 percent of urban health departments surveyed by CityMatCH reported having the capacity to meet the demand for immunization services (Hubbert and Peck, 1993). As noted earlier, the limited number of health care providers in



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