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Transcript of Immunization Programs’ Challenges and Opportunities: We Are In This Together AIM Program Managers...
Immunization Programs’ Challenges and Opportunities:
We Are In This Together
Immunization Programs’ Challenges and Opportunities:
We Are In This Together
AIM Program Managers MeetingAIM Program Managers MeetingJanuary 20, 2010January 20, 2010
Atlanta, GAAtlanta, GA
Lance E. Rodewald, MDLance E. Rodewald, MD
Director, Immunization Services DivisionDirector, Immunization Services Division
National Center for Immunization and Respiratory Diseases, CDCNational Center for Immunization and Respiratory Diseases, CDC
Working Together is Essential Working Together is Essential When the Job is ToughWhen the Job is Tough
TopicsTopics
PerformancePerformance
Opportunities and challengesOpportunities and challenges
ResourcesResources
PlanningPlanning
PERFORMANCEPERFORMANCE
Heterogeneously high coverage for young childrenHeterogeneously high coverage for young children
Room to improve for teens and influenzaRoom to improve for teens and influenza
Adolescent Immunization, Adolescent Immunization, U.S., 2006 - 2008U.S., 2006 - 2008
Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv
Adolescent Immunization by Adolescent Immunization by Race and Ethnicity, 2008 (1)Race and Ethnicity, 2008 (1)
Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv
Teen NIS Results by Race and Teen NIS Results by Race and Ethnicity, 2008 (2)Ethnicity, 2008 (2)
0102030405060708090
100
Td/Tdap Tdap 1+ MCV4 1+ HPV4, 1-dose
HPV4, 3+ doses
White, non-Hispanic
Black, non-Hispanic
Hispanic
AI/AN, non-Hispanic
API, non-Hispanic
Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv
Adolescent Immunization and Adolescent Immunization and Federal Poverty Level, 2008Federal Poverty Level, 2008
Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv
0
10
20
30
40
50
60
70
80
90
100
Dt/Dtap; NIS-Teen – 2008State-Level Coverage Rates
Source: MMWR 2009;58:997
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
Dtap; NIS-Teen – 2008State-Level Coverage Rates
Source: MMWR 2009;58:997U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
MCV4; NIS-Teen – 2008State-Level Coverage Rates
Source: MMWR 2009;58:997
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
1-Dose HPV4; NIS-Teen – 2008State-Level Coverage Rates
Source: MMWR 2009;58:997
U.S. National Average: Blue
0
20
40
60
80
100
1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006
Percent
Increasing Vaccine-Specific Coverage Increasing Vaccine-Specific Coverage Rates Among Preschool-Aged ChildrenRates Among Preschool-Aged Children
† DTP(3+) is not a Healthy People 2010 objective. DTaP(4) is used to assess Healthy People 2010 objectives.
Note: Children in the USIS and NHIS were 24-35 months of age. Children in the NIS were 19-35 months of age.
Source: USIS (1967-1985), NHIS (1991-1993) CDC, NCHS, and NIS (1994-2006), CDC, NIP and NCHS; No data from 1986-1990 due to cancellation of USIS because of budget reductions.
DTP / DTaP(3+)†
MMR(1+)
Hib (3+)
2010 Target
Hep B (3+)
Polio (3+)
Varicella (1+)
PCV 7 (3+)
0
10
20
30
40
50
60
70
80
90
100
431331; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
3 Hep B; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
Hep B Birth Dose; NIS – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
2 Hep A; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
1 MMR; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
Vaccination Coverage Levels at 19-35 Vaccination Coverage Levels at 19-35 Months of Age by Race and Ethnicity, Months of Age by Race and Ethnicity,
1995 – 2008; MMR 1+1995 – 2008; MMR 1+
Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv
Omer S, et al. NEJM 2009;360:1981-1988
Measles Cases Reported to CDC/NCIRD January 1 to July 11, 2008 (N= 132)
San Diego, CAOutbreak N=12(CA =11, HI =1) Source=Switzerland, D5 Jan 25-Feb 16
Missaukee County, MI Outbreak, N=4 Source=Unknown, D5 Feb 29-Apr 8
Pima County, AZ Outbreak N=18 Source=Switzerland, D5 Feb 13-May 2
Los Angeles, CA N=2 Source=Unknown Mar 23-Apr 16
Fairfax, VA N=1 Source=India Feb 25
Milwaukee County, WI Outbreak, N=6 Source=China-H1Mar 19-Apr 25
Nassau County, NY N=1, Source=Israel
Apr 4
New York City, NYN=27 Sources:
Israel (1) Belgium (2) D4
Italy (1)Other Import-
associated (10)Source Unknown (13)
Jan 18-Jun 10
Honolulu, HIN=4 Sources:Italy (2)China (1)Philippines (1)Feb 5-May 22
Pittsburgh, PA N=1 Source=Unknown Apr 12
Chicago, ILN=1 Source=Switzerland Apr 17
Grant County, WAOutbreak N=19Source= JapanApr 12 - May 30
Vernon County, WI N=1 Source=GermanyApr 25
Scott County, ARN=2Source= UnknownFeb 12-Feb 22
San Francisco, CA N=2, Sources:India (1), Italy (1) Apr 18, Jun 22
D.C. N=1Source Unknown Apr 20
Chaves Co, NM N=1, Unknown Mar 17
Baton Rouge , LA N=1, Russia May 14 Du Page Co, I L
Outbreak N=27Source=Italy, D4 May 15-Jun 25 Fulton Co, GA
N=1 Pakistan May 14
Cass Co, MO N=1Source Unknown Apr 7
0
10
20
30
40
50
60
70
80
90
100
3 Hib; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
Coverage Measurement for Hib Coverage Measurement for Hib Vaccine in Face of the ShortageVaccine in Face of the Shortage
Prior to 2010, NIS did not distinguish among Hib vaccinesPrior to 2010, NIS did not distinguish among Hib vaccines
Practicing correctly during shortage could result in being UTD Practicing correctly during shortage could result in being UTD or not UTD depending on the vaccineor not UTD depending on the vaccine– In 2008 NIS, 8% of children vaccinated in shortage monthsIn 2008 NIS, 8% of children vaccinated in shortage months
Dip in coverage seen will increase, but differently for states Dip in coverage seen will increase, but differently for states depending on their prior Hib vaccine selectiondepending on their prior Hib vaccine selection
NIS changed to capture specific product starting in 2010NIS changed to capture specific product starting in 2010
If NIS change does not allow correct determination, will have to If NIS change does not allow correct determination, will have to have policy decision on coverage measurement for Hibhave policy decision on coverage measurement for Hib
RATIONALE FOR REACHING MORE CHILDREN AND ADULTS
Immunization Program PerspectiveImmunization Program Perspective
Foundation for the ARRA-Immunization Spend Plan:Section 317 Report to Congress
Annual estimate for “optimum State and local operations funding, as well as CDC operations … to conduct and support childhood, adolescent and adult [immunization] programs.”
Beginning in FY 2007 and each subsequent fiscal year
FY 09– Appropriation $557.4 million
– Estimated need $1,315.6 million (vaccine purchase and operations)
– Funding gap: $758.2 million
VaccineVaccine
Programs blend entitlement vaccine funding with discretionary vaccine funding– Only entitlement funding grows with need
– Need has increased markedly since 2000
Growth in need raises expectations on discretionary vaccine funding, federal and state
Consequences of unmet expectations is significant– Delayed introduction of new vaccines
– Incomplete implementation of vaccines
– Decisions about vaccine implementation varies by state
Grantees Provision of Vaccines to Grantees Provision of Vaccines to Underinsured Children, 2006 (N=49)Underinsured Children, 2006 (N=49)
0%
20%
40%
60%
80%
100%
% s
upply
ing to u
nderinsu
red Yes No/Not yet Missing
Source: Grace Lee et al; Harvard University
Implementation of MCV4Implementation of MCV4
0
10
20
30
40
50
60
# o
f G
ran
tees
VFC 317 State/Grantee
FDA
CDC
ACIP
MMWR
Lancet 2008 March 15; 371:881-882
OperationsOperations
Vaccine use has increased markedly since 2000, but operations funding has grown much less– Fewer dollars per dose to support vaccination efforts
– Vaccination environment is more difficult
State budget declines are shrinking public health programs
Local public health is experiencing reductions in workforce due to budget cuts– Loss of capacity
– Loss of expertise
Opportunity Afforded by Reaching More Children and Adolescents Project
States determine vaccination projects– Addresses variation in vaccine implementation by state
– Best fit with local health system environment
Many different projects proposed– Tdap vaccination of newborn contacts
– Health care workers and influenza or Tdap
– Hepatitis B vaccine in STD clinics
Allows states to make progress against VPDs
Risks and ChallengesRisks and Challenges
Challenges– One-time funding
– Starting and stopping program activities
Risks– Not using all of the available funding
– H1N1 activities competing with ARRA-317 activities at state level
Outcomes DesiredOutcomes Desired
Direct public health benefit
Demonstration that Section 317 has capacity to do more and make good on the funding investment
Increased experience at state level for new vaccination projects
IMPROVING REIMBURSEMENT IN PUBLIC HEALTH DEPARTMENT CLINICS
Description and Section 317 Perspective Rationale
A Basic Question
Insurance plans pay for immunizations at primary care provider offices
Some children or adults will present to the health department for vaccination for many reasons– Provider does not offer specific vaccine– Patient does not have provider– Convenience of health department– Inability to pay for office visit
Should the insurance plan covering vaccination services be billed for services rendered in health department clinics?
Rationales for “Yes” Answer
Public health should be paid for work performed, just as anyone else should (equity)
Parents and employers pay the health plan for vaccinations; health plans should not be subsidized with government money when they have private money for same service (common sense)
Paying for those already covered privately limits what programs can do with their scarce public resources (stewardship)
Billing Practices
One systematic study from 2001 on health department billing– 94% bill Medicaid for their assigned pts
– 64% bill Medicaid for referred pts
– 31% bill private insurance
Santoli J, et al. AJPM 2001; ;20(4):266–271)
How Did This Situation Happen? – History and Barriers
Desire to never turn a child away (no missed opportunities)
Vaccines used to cost much less
Health department clinics generally not set up at “in-network” providers to bill private health insurance – there are barriers to participation
THE OREGON EXPERIENCE
Why?
Increased cost to vaccinate a child from new vaccines
Pressure on Section 317 as a resource for vaccinating (mismatch between VFC and Section 317 funding)
Oregon had to become “less inclusive” in their statewide immunization program
Oregon’s Approach
Study local health department payor mix
Strategic planning with all stakeholders with data as basic input
Recommendation of stakeholders to no longer support immunization of well-insured individuals
Survey of billing practices
Consensus process to implement plan
Oregon’s Results: Increased Revenue and Sparing of Section 317 Funding
Oregon’s Results: Increased Revenue and Sparing of Section 317 Funding
Oregon’s Results: Increased Revenue and Sparing of Section 317 Funding
Public Health Impact
14 Grantees Funded Through ARRA-317 Innovative Projects to Improve Reimbursement in Public Health Department Clinics
NYC
Expected Outcomes
Executable plans
Revenue stream to sustain public health capacity
Lessons for further promotion
Long-term stabilizing force for shared public/private immunization effort
FUNDING STATUSFUNDING STATUSOperations and VaccineOperations and Vaccine
Immunization Program Operations Immunization Program Operations FundingFunding**: FY06 – FY10: FY06 – FY10
* Shown in millions of dollars; includes Section 317 and VFC
Immunization Program Operations Immunization Program Operations FundingFunding**: FY06 – FY10: FY06 – FY10
FY06 FY07 FY08 FY09 FY10 Min FY10 Max
New** 255.1 262.9 257.4 277.4 276.7 280.4
Carryover 23.1 17.7 5.0 19.1 8.1 8.1
Pan flu 15.4 15.7 14.0 15.7
ARRA 79.7 79.7
Total 278.2 280.6 277.9 312.2 378.4 383.8
* Shown in millions of dollars; includes Section 317 and VFC** Includes DA and travel
VFC Non-Vaccine FundingVFC Non-Vaccine Funding**: : FY09 – FY10FY09 – FY10
* Shown in millions of dollars
VFC Non-Vaccine FundingVFC Non-Vaccine Funding**: : FY09 – FY10FY09 – FY10
FY09 FY10
OPS 23.7 26.4
Ordering 8.8 8.3
Distribution 0.5 0.6
AFIX 37.7 38.6
DA Other 0.6 0.2
DA Personnel 2.0 2.4
Carryover 0.4 0.3
Total 73.6 76.8
* Shown in millions of dollars
Vaccine Funding to Grantees: Vaccine Funding to Grantees: FY06 – FY10FY06 – FY10
Immunization Program Vaccine Immunization Program Vaccine FundingFunding**: FY06 – FY10: FY06 – FY10
FY06 FY07 FY08 FY09 FY10
VFC 1,681 2,423 2,434 2,978 3,285
Section 317 225 244 255 256 254
ARRA-317 44 124
Total 1,906 2,667 2,689 3,278 3,662
* Shown in millions of dollars; includes Section 317 and VFC
Program Funding Program Funding ObservationsObservations
Unprecedented level of resources, Unprecedented level of resources, vaccine and operationsvaccine and operations
Current resources are part-way to Current resources are part-way to CDC’s professional judgment levelCDC’s professional judgment level
Using one-time funding is a challenge, Using one-time funding is a challenge, but one worth meetingbut one worth meeting
The Cartoon Bank. Licensed for PowerPoint use, non-distribution
New Yorker CartoonAvailable from www.cartoonbank.com"Oh, that three billion dollars." Product SKU: 125371
LOOKING FORWARDLOOKING FORWARD
Using Your Enhanced Influenza Using Your Enhanced Influenza ProgramsPrograms
H1N1 provided unprecedented expansion of H1N1 provided unprecedented expansion of influenza vaccination capacityinfluenza vaccination capacity
Strong interest in using new capacity for Strong interest in using new capacity for seasonal vaccination effort, without missing seasonal vaccination effort, without missing the 2010 vaccination seasonthe 2010 vaccination season
School-located vaccination, obstetricians, School-located vaccination, obstetricians, increased pediatrician interest, community increased pediatrician interest, community vaccinators, etc.vaccinators, etc.
Making the Most of ARRA-317Making the Most of ARRA-317
ARRA challengesARRA challenges– One-time fundingOne-time funding
– H1N1 opportunities costsH1N1 opportunities costs
Not using funding weakens argument that Section Not using funding weakens argument that Section 317 is underfunded317 is underfunded
Principles and policy for flexibility, grantee priority, Principles and policy for flexibility, grantee priority, and using the funding prior to end of FY2010and using the funding prior to end of FY2010
Policy implementation involves collaboration and Policy implementation involves collaboration and sharing across programs: sharing across programs: working togetherworking together
Pediatrics 2009;124:S571-S572
VFC and Delegation of Authority for Underinsured Children
VFC legislative proposal has not been introduced in Congress
Delegation of VFC authority from FQHC/RHCs to other VFC providers:– Is occurring (CDC is aware)
– Is being honored (CDC allows VOFA to include delegated sites)
– Is not currently being provided guidance by CDC
Programmatic options for delegation of VFC authority are being developed within HHS
VTrckS Implementation
Business transformation at CDC– Purchase to Pay
– Order to Distribute
– Real-time data systems
Capacity transformation in programs– Retirement of VACMAN
– Orders can be placed by providers
– IIS interfaces supported
Time line is aggressive in FY2010
ARRA-317 and ARRA-HITECH IIS Projects
Limited competition cooperative agreements to increase interoperability between EMRs and IIS– Addresses persistent IIS challenge of duplicate data entry
– Strong move toward real standards
– Two-year project period
Exportable, usable ACIP-standard algorithms for IIS– Minimizes annual reprogramming
Conclusions (1)
Immunization programs are high-performance public health programs
Support for immunization programs is very strong– Coalitions of public and private sectors are working hard to
support your efforts
– Resources are improving at a judicious pace
Many opportunities exist to protect more people from vaccine preventable diseases
Conclusions (2)
2010 presents fundamental challenges– ARRA-317 represents a critically important opportunity that
cannot be missed
– Capitalize on your H1N1 successes for seasonal influenza
– Prepare for VTrckS implementation to move forward
We are all in this together to fulfill the potential of vaccines to prevent suffering from preventable diseases
Let’s Talk About All This
EXTRA SLIDES
Adolescent Immunization, Progress Toward HP2010 Objectives
Vaccine HP 2010 Objective 2008 Teen NIS results
MMR, 2+ 90% 87.9%
Hep B, 3+ 90% 89.3%
Td/Tdap 90% 72.2%
Varicella vaccine or disease
90% 92.7%
Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv
Adolescent Immunization, Progress Toward HP2010 Objectives
Vaccine HP 2010 Objective 2008 Teen NIS results
MMR, 2+ 90% 87.9%
Hep B, 3+ 90% 89.3%
Td/Tdap 90% 72.2%
Varicella vaccine or disease
90% 92.7%
Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv
3-Dose HPV4; NIS-Teen – 2008State-Level Coverage Rates*
Source: MMWR 2009;58:997* States with cell sizes too small are not included
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
4 DTaP; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
3 Polio; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
1 Varicella; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
0
10
20
30
40
50
60
70
80
90
100
4 PCV7; NIS 19 to 35 mo. – 2008State-Level Coverage Rates
Source: MMWR 2009;58:921
U.S. National Average: Blue
Oregon’s Procedure