acquired. Similarly, some private health care providers find it convenient and less costly to refer their clients to public health clinics for immunizations, even though federal officials have sought to discourage this type of referral practice through advisory notices and consultations (Richardson, 1999; Richardson and Orenstein, 1999). Public health departments are facing decreased revenues from third-party payers, such as Medicaid, for immunizations because of the rapid growth in capitated arrangements. Consequently, public health officials in some areas now negotiate payment plans for immunizations with HMOs or actively discourage private provider referrals through the use of screening questions. The result is a series of mixed signals and increased paperwork for clients and public providers that can result in missed opportunities for immunization within populations with startlingly low coverage levels.

VFC has also contributed to the vaccine delivery system’s shift toward the private sector. A total of 43,000 health care provider sites have enrolled in VFC, and the majority of these (approximately 70 percent, or 30,000) are private provider sites (NVAC, 1999a). By providing free vaccine to primary care physicians, VFC attempts to keep children in their medical homes (their regular source of primary care) and decreases private provider referral of patients to public clinics for immunizations (NVAC, 1999a).


The complexity of vaccine supply and immunization delivery arrangements creates a dilemma for surveillance efforts. Private health plans have assumed responsibility for providing personal health services to public program beneficiaries, but are not readily held accountable for ensuring that all of their enrolled clients are kept up to date in their immunization status. Public agencies continue to deliver vaccines to disadvantaged adults and children, and also retain the responsibility for assessing records and auditing data for public program beneficiaries in both private and public health care settings. Yet the enrollment growth among Medicaid beneficiaries in capitated plans that do not bill for individual services has reduced public agencies’ ability to monitor service delivery for vulnerable populations. Record scattering and patient movement both on and off Medicaid and between health plans (known as “cycling”) have also made immunization records management more difficult. A clearer definition of responsibility for ensuring immunization services and conducting surveillance efforts is needed between the private and public sectors, as well as among public health agencies such as Medicaid, Medicare, and state immunization programs.

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