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

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Dt/Dtap; NIS-Teen – 2008State-Level Coverage Rates

Source: MMWR 2009;58:997

U.S. National Average: Blue

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Dtap; NIS-Teen – 2008State-Level Coverage Rates

Source: MMWR 2009;58:997U.S. National Average: Blue

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MCV4; NIS-Teen – 2008State-Level Coverage Rates

Source: MMWR 2009;58:997

U.S. National Average: Blue

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100

1-Dose HPV4; NIS-Teen – 2008State-Level Coverage Rates

Source: MMWR 2009;58:997

U.S. National Average: Blue

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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+)

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431331; NIS 19 to 35 mo. – 2008State-Level Coverage Rates

Source: MMWR 2009;58:921

U.S. National Average: Blue

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3 Hep B; NIS 19 to 35 mo. – 2008State-Level Coverage Rates

Source: MMWR 2009;58:921

U.S. National Average: Blue

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Hep B Birth Dose; NIS – 2008State-Level Coverage Rates

Source: MMWR 2009;58:921

U.S. National Average: Blue

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2 Hep A; NIS 19 to 35 mo. – 2008State-Level Coverage Rates

Source: MMWR 2009;58:921

U.S. National Average: Blue

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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

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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

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# 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

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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

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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

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1 Varicella; NIS 19 to 35 mo. – 2008State-Level Coverage Rates

Source: MMWR 2009;58:921

U.S. National Average: Blue

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4 PCV7; NIS 19 to 35 mo. – 2008State-Level Coverage Rates

Source: MMWR 2009;58:921

U.S. National Average: Blue

Oregon’s Procedure