Calling the Shots Immunization Finance Policies and Practices (2000) / Chapter Skim
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Immunization Finance Policies and Practices
Immunization Finance Policies and Practices
Pages 142-192
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From page 142... ...
When public health clinics served as the primary point of service for delivering immunizations directly to disadvantaged populations, they had self-contained programs that performed multiple functions, including the purchase and administration of vaccines, the measurement of infectious disease patterns, the analysis of vaccine coverage rates and safety concerns, the development of programs to improve immunization 142
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From page 143... ...
The policy role of public health agencies was thus expanded to include encouragement and oversight of private-sector performance in meeting national immunization goals; however, the VFC program did not provide the additional administrative resources that would enable the exercise of these functions at the local level. This redefinition of roles and responsibilities occurred during a time when federal resources for state immunization infrastructure efforts were diminishing, and greater reliance was being placed on the states and the private sector to meet national health needs.
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From page 144... ...
whether private health plans monitor the immunization coverage levels of their members to determine whether their rates are up to date, and (3) whether private health plans are prepared to take action to improve coverage rates if disparities are found within their membership or their members' communities.
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From page 145... ...
, SCHIP, and VFC. These same recommendations are considered by private health plans and state health agencies, which issue guidelines and enact requirements for their own populations, including immunization standards for school entry, day care licensing, and insur
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From page 146... ...
State officials have indicated, however, that they often avoid adding such requirements to Medicaid health plans because doing so would make the plans unduly burdensome, and could discourage private providers or managed care organizations from participating in Medicaid at all or enrolling hard-to-reach participants. Similarly, private health plans with Medicaid or SCHIP contracts may incur additional costs in the use of evidence-based prevention strategies, such as recall and/or reminder systems, immunization registries, practice-based coverage assessments, and provider education.
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From page 147... ...
Such exclusionary practices are difficult to detect, especially in the absence of small-area population-based assessments that have sufficient sensitivity to reveal disparities in coverage rates and service utilization patterns among vulnerable groups. The lack of national or state-level trend data for Medicaid and other disadvantaged populations within private health plans (whether capitated managed care organizations or fee-for-service)
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From page 148... ...
146 DING ~ Same ~ Immunizations for adolescents and adults may generate b1Us' but such data often are not avad~le in a form that Would aunt comparisons of service patterns across heals plans or regions. ~ Although some plans may incur costs for developing and maintaining medical records data' Me costs of comp1Ung (or searching)
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From page 149... ...
have described in detail the information gathering and analytical functions associated with these roles. Since the delivery of immunization services has shifted from the public to the private sector over the past decade, careful attention will need to be focused on ways to gather and compare data on immunization status, vaccine coverage benefits, and service-delivery costs from both public and private health insurance plans.
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From page 150... ...
At the same time, private health plans and providers need to share the burden of incorporating prevention efforts into their practices and programs (see Box 5-2~. A shared partnership, responsive to local needs and resources, can integrate public health activities within the complex maze of state health finance and health insurance initiatives to improve the health status of vulnerable groups.
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From page 151... ...
Needy populations are increasingly receiving care within the private health sector as Medicaid and S CHIP contract with health plans to provide benefits, including immunizations. However, the absence of reliable indicators of this shift to privately managed care has made it more difficult to monitor immunization coverage levels for the total population as well as vulnerable groups.
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From page 152... ...
Such efforts must involve partnerships with national, state, and local professional groups and private health plans so that common strategies can be developed and implemented at the local level. States require incentives as well asfinancial assistance if these public-private partnerships are to be implemented at the local level to improve the quality of local immunization services and sustain high rates of immunization coverage among vulnerable populations.
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From page 153... ...
, in the early 1990s local health departments used Section 317 funds to develop new immunization programs in such areas as increased assessment, outreach, performance measurement, program linkages, and information management (NACCHO, 1999~. Staff time and clinic hours devoted to immunization activities increased in urban areas, and health clinics were established in rural areas and isolated communities to improve access to immunization services.
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From page 154... ...
, contributed to the increased coverage rates reported during the past decade. Impact of Program Cutbacks and Budget Reductions When federal appropriations for infrastructure grants began to decline in 1996, local budgets for immunization services were substantially reduced, and in some cases eliminated entirely (programs were eliminated, for example, in Duvall County, Florida; Zanesville-Muskingum County, Ohio; Noble County, Ohio; Dakota County, Minnesota; and Hennepin County, Minnesota)
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From page 155... ...
Local health departments have the capability to play important roles in working with public- and private-sector providers to assess and improve immunization coverage rates. However, they require state and federal assistance to perform these roles.
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From page 156... ...
. · Create and enforce state mandates for the inclusion of immunization benefits in private health insurance plans.
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From page 157... ...
The vast majority of infrastructure support for immunization within the states comes through Section 317 grant awards administered by CDC. Following the 1989-1990 measles outbreaks, federal and state officials expressed alarm about the adequacy of existing immunization delivery systems and identified strategies designed to improve immunization coverage rates among vulnerable populations.
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From page 159... ...
159 ~ ~ a, ~ o o · _1 · ~ 5- 5o o ·_1 · o o CD ·_1 ·_1 , o he ·_1 5o CD CD o o CD CD .
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From page 160... ...
Health agencies realized that they were expected to assume new responsibilities that were difficult to justify and were unable to obtain the necessary resources to exercise this role. States initially had broad discretion in the use of federal funds, although CDC provided guidance each year to emphasize certain program objectives and priorities.
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From page 161... ...
Self-reports by the states indicated that they expected to provide $109 million for vaccine purchase and $231 million for program operations to support immunization efforts in the year 2000. This figure includes funds provided by other federal agencies that are used within the state for immunization programs, along with state-level revenues and private resources.
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From page 162... ...
162 lo o to Cat to to UP Cal o o o o o o .
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From page 163... ...
More common across states is indirect support of the immunization program through intergovernmental transfers, involving other state or federal programs or services. In addition, many states provide in-kind contributions in the form of assistance from school nurses and secretaries, who conduct school-based assessments of children's immunization status, and from local health departments (e.g., facilities and overhead, and locally funded staff who perform multiple duties, including the delivery of immunizations)
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From page 164... ...
In 1994, an additional $30,672,686 in appropriated vaccine purchase funds was paid directly to the Department of the Treasury for floor stock excise taxes on behalf of all the grantees when the Vaccine Compensation Act was reauthorized. aFunds awarded in previous years but not obligated.
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From page 165... ...
The committee is persuaded that solutions will require state collaboration with local health departments, private providers, state and local chapters of providers' professional organizations, community groups, and others. States should be exploring how to strengthen primary care to meet not only children's immunization needs but also their other important health care requirements.
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From page 166... ...
Residual needs for vaccine remain in most public clinics, reflecting the realities of serving vulnerable children and adults who have urgent needs and are unable to take advantage of other health care resources. Furthermore, the clientele of public health clinics has changed; the current clientele requires more effort to maintain and improve immunization status because they are often more transient, more socially isolated within their community, and more likely to have contact with multiple health care providers in the public and private sectors.
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From page 167... ...
IMMUNIZATION FINANCE POLICIES AND PRACTICES 167 TABLE 5-3 Estimated Vaccination Coverage with 4 3 1 3a Series Among Children 19-35 Months of Age by Provider Type, Census Division, and State United States, National Immunization Survey (NIS) , 1998b Vaccinated Vaccinated Vaccinated Vaccinated NIS by Public by Private by Mixed by Other Population Provider Provider Providers Provider Division/State Sizer (%)
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From page 168... ...
SOURCE: CDC, l999e. ment measures will count the immunization status of the patient regardless of service-delivery setting)
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From page 169... ...
As was the case with local health departments, discussed earlier, these reductions caused states to cut back many immunization efforts, including assessment, outreach, performance monitoring, program linkages, and information management (see Table 5-4~.7 Two of the most common activities initiated with the original increases in Section 317 funding outreach and education efforts and expanded service deliverywere also the most common targets of cuts (Freed et al., 1999~. For example: · Almost all state program managers made substantial cuts in contracts with local health departments, even though they viewed local outreach activities as critical and effective.
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From page 170... ...
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From page 171... ...
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From page 173... ...
Such alternative sources included other federal funding, redirection of state vaccine purchase funds to infrastructure support, and additional state funding, among others. Only 11 states were able to replace federal funds for vaccine purchase with funds provided by their health departments and/or state legislatures.
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From page 174... ...
The loss of federal funds in Section 317 infrastructure grants has diminished state and local activities in such areas as immunization services, outreach, educational programs, data surveillance and measurement, and technical assistance. These reductions have impaired the ability of state health agencies to carry out effective assessment, assurance, and policy development roles.
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From page 175... ...
FEDERAL ROLES AND RESPONSIBILITIES 175 The National Immunization Program (NIP) within CDC is the primary agency concerned with federal policy and practices in support of state immunization efforts.
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From page 176... ...
integrating immunization services within comprehensive primary care plans and medical homes in the private health care sector. Congress has formulated specific guidance for the development of the national immunization program in a few additional areas as well: · In the initial buildup of the Section 317 infrastructure grants, Congress clearly intended that federal funds be used to improve access within high-risk communities by extending clinic hours and hiring staff to administer immunizations (U.S.
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From page 177... ...
These areas also reveal challenges that emerge when federal and state agencies attempt to guide or change professional practices within the private health care sector. Recently, legislation has been introduced that seeks to require comprehensive health insurance coverage for childhood immunization.9 But such initiatives must address the complex regulatory structure for group and individual health insurance coverage within the private sector and face the traditional political resistance to federal mandates for the private health insurance system.
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From page 178... ...
Four factors affected the buildup and subsequent cutbacks in the Section 317 state infrastructure grants: · Implementation of a pockets-of-need strategy. · Use of incentive grants to improve immunization rates within the · The existence of significant carryover in the early years of the state infrastructure grant awards.
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From page 179... ...
In 1999 NVAC once again called on CDC and state and local immunization programs to focus resources on underimmunized populations. Immunization programs were encouraged to collaborate with WIC to assess each enrolled child's immunization status, and state immunization
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From page 180... ...
In recent years, as the total funding for infrastructure grants has diminished, the $33 million set-aside has become an increasing source of concern. Incentive grants now represent about 24 percent of the total grant awards, and grantees with low immunization coverage rates have indicated that they are being "punished" by lower total awards when they require additional assistance to meet urgent local needs.
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From page 182... ...
The delay in expenditures during the startup period led Congress to reduce the state infrastructure grant funds in the period FY 1996-1998.~5 These reductions resulted from mid-decade pressures to reduce the size of federal discretionary programs in general, making it more difficult to sustain ongoing efforts while also starting up new initiatives, such as the polio eradication program. The decreases are commonly viewed by state officials as "punishment for factors beyond their control" (Freed et al., 1999:16~.
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From page 183... ...
House of Representatives, 1996~. Recognizing that prior increases had occurred in the state infrastructure grants, and disturbed by reports of large amounts of unspent state funds from prior years, the Congress expressed strong support for the global polio eradication program and encouraged CDC to expand the effort using available resources by reducing the state infrastructure grant awards.
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From page 184... ...
CDC also encouraged the development of immunization registries as a key component of the future immunization surveillance system. Between 1994 and 1999, CDC allocated a total of $178.4 million in Section 317 funds within the state infrastructure awards to support immunization registries, but the size of these awards has declined in recent years (see Box 5-4)
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From page 185... ...
But those who are involved in negotiating Medicaid or SCHIP contracts may be unaware of or reluctant to involve other state employees in developing benchmark and performance standards for their contractors. · Programs to improve immunization coverage rates The reductions in federal grants have had significant effects on interventions such as outreach, provider education, and service delivery, as described earlier.
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From page 186... ...
to $170 million (38 percent of the total budget in FY 1999~. In the same period, the grants portion of the budget (which includes state infrastructure and vaccine purchase grants, research support, and congressionally mandated studies)
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From page 187... ...
Programs such as VFC, Medicaid, and S CHIP have administrative resources that can help states monitor vaccine coverage rates among public and private health providers. However, no coordi
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From page 188... ...
have access to vaccines in the private sector through plans that are financed with Medicare funds. While the expanded role of the private sector in serving disadvantaged populations has served important public health objectives by increasing coverage rates, significant questions remain about the adequacy of existing services, as well as the capability of private providers and health plans to offer timely and routine vaccinations.
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From page 189... ...
As part of their mission, public health leaders and programs bear responsibility for encouraging private providers to incorporate evidence-based strategies and new vaccines into routine primary care services, participating in regional registries, monitoring and improving immunization coverage rates in the public and private health sectors, and addressing concerns about vaccine safety. Local and state governments have demonstrated both interest and ability with regard to developing immunization programs and services that have positive populationwide benefits, but few states have the resources needed to sustain infrastructure programs on their own.
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From page 190... ...
Although state and local health programs have been urged to assume new leadership and oversight roles (such as strengthening coordination with new health finance practices, monitoring immunization status within private health care plans, and developing registry initiatives) , it is unlikely that such efforts can be undertaken on a national scale without federal funding committed to their support.
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From page 191... ...
The survey also indicated that adult vaccines are least likely to be covered: 57 percent of employers' most popular health plans included coverage for influenza vaccines, while only 41 percent covered pneumococcal vaccines.
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From page 192... ...
to monitor coverage rates, although private provider assessments (36) and, more rarely, managed care plan assessments (17)
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