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Calling the Shots: Immunization Finance Policies and Practices (2000)

Chapter: Appendix E: Overview of Case Studies and Site Visits

« Previous: Appendix D: Overview of State Survey
Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×

Appendix E
Overview of Case Studies and Site Visits

This overview describes the purpose and the methodology of the committee’s case studies and site visits. Information gathered through these efforts is incorporated in the body of the report, often featured in the boxes accompanying the text. A more detailed presentation of the findings of the individual case studies and site visits is contained in a forthcoming special issue of the American Journal of Preventive Medicine, (v. 19 [3S], October 2000) devoted to the research conducted in the development of this report.

The committee undertook eight state or locality-specific case studies in order to deepen the picture of local policy choices and performance of immunization programs and spending over the past decade. The state survey conducted for the committee by Dr. Gary Freed and associates provides a comprehensive view of the significant programmatic features and issues regarding immunization across the country (see Appendix D for a brief description of this survey). The individual case studies were designed to:

  • trace program changes, development, and performance over time,

  • collect detailed information on state- (and in the case of Los Angeles and San Diego, county-) level spending for immunization-related activities, and

  • document the impact of federal policy directions and funding levels on state programs over the past decade.

Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×

The sampling of states and localities is far too small to be statistically representative, and the findings of the case studies cannot be used by themselves to make national generalizations, at least as regards state-level program models and policy choices. Nevertheless, the case studies and site visits allowed the committee to pursue questions about the implementation of national program and funding policies across an array of states. They also gave committee members, staff, and consultants the opportunity to communicate directly with state and local immunization and health program managers in a sustained fashion on several occasions, which provided much insight into the impact and importance of federal policies.

The sites chosen were Maine; New Jersey; North Carolina; Alabama; Michigan; Texas; Washington; and, in California, Los Angeles and San Diego Counties. These states and counties were selected because they vary demographically, and because their immunization policies and program structures reflect distinctive choices that convey a sense of the variety among all the states in immunization strategies, challenges, and achievements. Table E-1 displays notable demographic statistics for these states (California data are used for Los Angeles and San Diego Counties), Table E-2 shows immunization-related public policies and programmatic features; and Table E-3 displays Section 317, VFC, and state-source immunization spending for 1995 and 1998.

The framework for developing profiles of individual states and the data elements to be collected for all cases were designed by staff and reviewed by the committee. A subcommittee to oversee the conduct of the case studies was formed, and members of this subcommittee, as well as members of the committee at large, participated in site visits and were involved in both the written and oral presentation of findings to the rest of the committee.

Four site visits were conducted to large metropolitan areas known to have pockets of need and/or overall low immunization coverage rates:

  • Detroit, Michigan;

  • Newark, New Jersey;

  • Houston, Texas; and

  • Los Angeles and San Diego, California (a combined visit).

Interviews with and visits to operating programs included the following in each of the sites:

  • county and municipal immunization program and health directors,

  • managed care organizations serving Medicaid and SCHIP clients,

  • persons using or developing immunization registries,

Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
  • WIC clinics or coordinators,

  • private-practice physicians, and

  • managers and practitioners in federally qualified health care centers.

The information gathered during the site visits was incorporated into each state’s case study.

The case study reports were developed through interviews with state health department officials, including the immunization program directors, Medicaid agency staff, budget analysts, and CDC public health advisors to the state, among others. These interviews were, in most cases, coordinated with the initial telephone interview conducted by the research team for the state survey to minimize the imposition on the state respondent’s time and avoid duplication. In addition to the interviews with key program managers, the case study sites were asked to provide detailed information on state spending from all revenue sources for immunization activities for the period 1992 through 1998:

  • federal grants,

  • state revenues (in the case of Los Angeles and San Diego, county revenues as well), and

  • foundation grants.

Reconstruction of this historical information, broken out by category of spending (e.g., personnel, contracts, aid to counties) was extraordinarily difficult and labor-intensive for the state health departments, involving the efforts of their own budget analysts and sometimes state budget office staff. The cooperation the committee received from all of the studied states in retrieving and reporting this information was extraordinary as well. The detailed reports of spending on immunization activities comprise an essential element of the information base used by the committee in developing its findings and recommendations.

Finally, the respective state grant applications to CDC for Section 317 funds for 1992, 1995, 1999, and 2000 were reviewed, providing another source of information over time for the case studies.

Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×

TABLE E-1 Demographic Characteristics of Case Study States

State

Child Pop (thousands)a

Birth Cohort (% National Cohort) b

Region

Fiscal Capacity Index (national rank)c

Maine

297

13,669 (.35)

New England

111 (19)

New Jersey

1,987

113,279 (2.9)

Mid-Atlantic

186 (1)

North Carolina

1,873

107,015 (2.8)

South

92 (31)

Alabama

1,071

60,914 (1.6)

South

68 (40)

Michigan

2,506

133,714 (3.4)

Midwest

88 (33)

Texas

5,577

333,974 (8.6)

South

62 (42)

Washington

1,455

78,190 (2.0)

North West

114 (17)

California

8,952

524,840 (13.5)

West

73 (38)

Los Angeles

2,518g

175,000

 

San Diego

 

45,000

 

National

69,528

3,880,894

 

100

aPopulation data from 1997. Cited in Kids Count Data Book. The Annie E.Casey Foundation, 1999.

bCited in National Vital Statistics Reports, 1997. 47(18):April 29, 1999.

cState per capita income divided by number of poor children in state, 1995 data. Toby Douglas and Kimura Flores, Urban Institute, March 1998.

TABLE E-2 State Program Characteristics

State

% in Medicaid Managed Carea

FMAPb

SCHIP Programc

State Vaccine Purchase

Maine

11

66%

Mixed

UPe

New Jersey

59

50%

Mixed

non-UP

North Carolina

69

63%

Sep. plan

UP

Alabama

71

69%

Mixed

non-UP

Michigan

68

54%

Mixed

Partial state purchase (for uninsured)

Texas

25

62%

Mixed

Partial state purchase (for uninsured)

Washington

91

52%

Sep. plan

UP

California

46

51%

Mixed

non-UP

Los Angeles

San Diego

a1998 Managed Care Enrollment, www.hcfa.gov/medicaid/mcstat98.htm.

bFMAP=Federal Medical Assistance Percentage, or federal matching rate for Medicaid service expenditures, at www.hcfa.gov.medicaid.

cSCHIP Plan Activity Map, 4/24/2000, at www.hcfa.gov/init/chip-map.htm.

Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×

% Children w/Medicaidd

% Children Uninsurede

% Non-White Births

% Children <100% FPLf

20

13

7

14

16

14

42

14

27

15

35

19

22

15

35

24

25

8

30

19

24

24

59

25

25

9

28

15

29

18

66

35

25

14

40

20

dPercentage data from 1996. Cited in Kids Count Data Book. The Annie E.Casey Foundation, 1999.

eCited in Kids Count Data Book. The Annie E.Casey Foundation, 1999.

fFPL=federal poverty level.

gPopulation data for Los Angeles County from U.S. Bureau of the Census, July 1, 1995.

Medicaid Vaccine Admin. Fee

First $ Coverage Required for Private Insurers

1998 Statewide Immunization Rates

1998 Metro Area Immunization Rates for Children≤FPLd

$5.00

No

89%

 

$11.50 in MCOf rates, passed thru

Yes

85%

Newark: 71.4%

$13.71/1 dose; double for>2

No

84%

 

$8.00/dose

No

84%

Jefferson County: 90.5%

$7/injection;

HMOs only

79%

Detroit: 72%

$3/oral

$5.00

Yes for plans since 1/98; no small employers

75%

Houston: 55%;

Dallas: 69%

$5.00

No

81%

 

$7.50/dose

Yes

78%

 

 

67%

 

73.5%

dFPL=federal poverty level.

eUP=universal purchase.

fMCO=managed care organization.

Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×

TABLE E-3 Section 317, VFC, and State Immunization Spending (dollars in millions [dollar per birth cohort member])

 

Vaccine Purchase

 

317 DA 1995

317 DA 1998

VFC DA 1995

VFC DA 1998

State Revs 1995

State Revs 1998

Maine

0.682

1.883

1.26

1.592

included in infrastructure

($/birth cohort)

[47.23

137.76

87.25

 

116.47]

 

New Jersey

1.673

1.916

2.654

3.259

0.02

0.02

 

[14.24

16.91

22.59

28.77

0.17

0.18]

North Carolina

1.985

3.154

4.129

10.92

7.875

10.737

 

[19.57

29.47

40.71

102.04

77.65

100.33]

Alabama

3.54

2.265

4.941

7.06

1

0.4

 

[58.09

37.18

81.08

115.9

16.41

6.57]

Michigan

4.987

10.463

9.071

12.742

3.911

0.101

 

[36.13

78.25

65.72

95.29

28.33

0.76]

Texas

6.476

9.098

28.023

34.524

19.863

13.731

[20.17

27.24

87.27

103.37

61.86

41.11]

Washington

2.512

3.266

3.106

6.008

3.534

7.082

 

[32.47

41.77

40.15

76.84

45.68

90.57]

California

6.987

9.241

51.319

72.555

 

 

[13.31

17.61

97.78

138.24]

 

Los Angeles

 

0.099

 

[0.57]

San Diego

 

0.05

 

[1.11]

National

96.304

135.562

247.692

399.974

 

 

[24.36

34.93

62.65

103.06]

 

NOTE: Los Angeles and San Diego include county as well as state spending. Texas includes separate 317 grants to Houston and San Antonio.

SOURCES: CDC, National Immunization program data for 317 and VFC. IOM case study data for state and local immunization spending. 1994 and 1997 birth cohorts: National Center for Health Statistics, Vital Health Statistics.

Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×

Infrastructure

317 FA 1995

317 FA 1998

VFC FA 1995

VFC FA 1998

State Revs 1995

State Revs 1998

1.228

1.665

0.233

0.495

0.1

0.5

[85.04

121.81

16.13

34.28

$6.92

36.58]

2.502

4.071

1.692

1.505

0.482

0.94

[21.29

35.94

14.4

13.29

4.1

8.3]

5.765

4.14

0.334

0.375

1.639

1.482

[56.84

38.69

3.29

3.5

16.16

13.85]

2.97

3.194

0.387

0.439

0.6

0.6

[48.74

52.43

6.35

7.21

9.85

9.85]

6.376

6.2

2.453

1.435

0.647

4.046

[46.19

46.37

17.77

10.73

4.69

30.26]

8.58

13.925

0.965

2.07

16.251

8.779

[26.72

41.69

3.01

6.2

50.61

26.29]

4.52

3.231

0.285

0.87

0.352

0.423

[58.43

41.32

3.68

11.13

4.55

5.11]

23.427

18.312

1.205

1.974

 

[44.64

34.89

2.3

3.76]

 

 

0.426

2.308

 

[13.19]

 

1.992

3.374

 

[74.98]

195.405

186.149

23.288

29.475

 

[49.42

47.97

5.89

7.59]

 

Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×

 

BOX E-1 Case Study Summary

The following authors prepared the eight case studies discussed in this report:

  • Alabama—Roy Hogan, M.P.A., Consultant, Austin, Texas

  • Maine—Kay Johnson, Ed.M., M.P.H., Johnson Group Consultants, Inc., Hinesburg, Vt.

  • Michigan—Hanns Kuttner, M.A., School of Public Policy Studies, University of Chicago

  • New Jersey—Gerry Fairbrother, Ph.D., Associate Professor of Epidemiology and Social Medicine, Montefiore Medical Center, New York City, and Paul Meissner, M.S.P.M., and Alana Balaban, B.Sc., Division of Epidemiology and Social Medicine, Montefiore Medical Center, New York City

  • North Carolina—Wilhelmine Miller, M.S., Ph.D., Program Officer, Institute of Medicine

  • Texas—Roy Hogan, M.P.A., Consultant, Austin, Texas

  • Washington—Heather McPhillips, M.D., M.P.H., Department of Pediatrics, University of Washington, and E.Russell Alexander, M.D., M.P.H., Professor Emeritus, School of Public Health, University of Washington

  • Comparison of Los Angeles and San Diego Counties, California— Gerry Fairbrother, Ph.D., Associate Professor of Epidemiology and Social Medicine, Montefiore Medical Center, New York City, and Elka Munizaga, Division of Epidemiology and Social Medicine, Montefiore Medical Center, New York City

The case studies are available on line at www.books.nap.edu/catalog/9836.html.

A summary article of the case study findings appears in the American Journal of Preventive Medicine (Fairbrother et al., forthcoming).

Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
Page 263
Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
Page 264
Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
Page 265
Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
Page 266
Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
Page 267
Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
Page 268
Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
Page 269
Suggested Citation:"Appendix E: Overview of Case Studies and Site Visits." Institute of Medicine. 2000. Calling the Shots: Immunization Finance Policies and Practices. Washington, DC: The National Academies Press. doi: 10.17226/9836.
×
Page 270
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Calling the Shots examines the basic strategies that finance the national immunization system in the current health care climate. It is a comprehensive volume, rich with data and highlighted examples, that explores:

  • The evolution of the system in light of changing U.S. demographics, development of new vaccines, and other factors.
  • The effectiveness of public health and health insurance strategies, with special emphasis on the performance of the "Section 317" program .
  • The condition of the infrastructure for control and prevention of infectious disease, surveillance of vaccines rates and safety, and efforts to sustain high coverage.

Calling the Shots will be an indispensable resource to those responsible for maintaining our nation's vaccine vigilance.

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