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EXECUTIVE OFFICE OF THE PRESIDENT
04- May- 1995 12: 00pm
TO:
(See Below)
FROM:
Gordon P. Agress
Office of Mgmt and Budget, HD
SUBJECT:
VFC Hearing
In today's oversight hearing, Senator Packwood took more
interest in VFC policy than in implementation. He focused on the
effect of vaccine cost on immunization rates, and seemed skeptical
that it was very important.
GAO reported that there is no evidence that cost is a major
barrier (but took pains to avoid saying it is not) ; CDC argued
that cost drove referrals, leading to missed opportunities.
Senators Mosely-Braun and Breaux focused on the importance of
prevention and the money saved by proper vaccination.
At one point GAO said CDC had agreed with their findings, citing
agreement on GAO's assessment of some diagnostic studies. When
Sen. Packwood followed up, Dr. Satcher noted that CDC might agree
narrowly that a particular study did not identify cost as a
barrier, without agreeing generally to a conclusion on the larger
question of the importance of cost. I thought his answer ended
that line of inquiry very effectively.
I will provide more details later.
Distribution:
TO:
Nancy-Ann E. Min
CC:
James I. Blount
CC:
Barry T. Clendenin
CC:
Richard J. Turman
CC:
Richard J. Turman
CC:
Jill M. Blickstein
CC:
Kashira D. Oldes
CC:
William G. White
CC:
Elisabeth S. Topel
CC:
Tina M. Kirk-Frank
CC:
Jim R. Esquea
CC:
Thomas M. Reilly
CC:
Victoria A. Wachino
EXECUTIVE OFFICE OF THE PRESIDENT
May- 1995 06: 25pm
TO:
(See Below)
FROM:
Gordon P. Agress
Office of Mgmt and Budget, HD
SUBJECT:
Senate Finance Hearing on VFC
The Senate Finance Committee today held oversight hearings on the
Vaccines For Children program. Chairman Packwood opened by saying
the program cost three and a half times the original estimates;
that cost of vaccine didn't seem to be the reason immunization
rates are low; and that he wasn't sure we needed this program. He
said he had called the hearings to examine the real barriers to
immunization. Other Senators attending included Moynihan,
Simpson, Mosely-Braun, and Breaux. GAO and CDC testified first,
followed by representatives from Mississippi, New York and the
Children's Health Fund. A wire service summary is attached.
GAO testified that there is no evidence that cost of vaccine is a
barrier to immunization. CDC argued that cost of vaccine does
cause referrals to public clinics and so contributes to missed
opportunities and low immunization rates, and that cost is one of
many barriers the Administration is trying to address. Sen.
Packwood didn't seem to think cost was an important barrier, and
Sen. Moynihan questioned the role of a Federal entitlement for
immunization. Sens. Mosely-Braun and Breaux argued that
vaccination is cost-effective, and that the focus should be on the
costs avoided. Details follow.
GAO - - No Evidence Cost Is a Barrier
GAO testified that it had found no conclusive evidence that cost
was a barrier to immunization. GAO took pains throughout the
hearing to note that it was not saying that cost was not a barrier
- - just that there is no evidence that it is. GAO said it based
its work on CDC studies. GAO said that other factors, such as
clinic access, provider and parent knowledge, and missed
opportunities, were major barriers.
CDC - - Cost Is One of Many Barriers
CDC Director Satcher argued that cost was one of many barriers to
immunization, and that the Administration's immunization
initiative had components to address all of these. He noted that
cost drove physician referrals of patients to clinics, and that
these referrals increased the likelihood of missed opportunities
and quoted a Journal of Pediatrics article that 93% of physicians
said that cost drove referral. He noted that there are many
barriers to immunizations, and that immunization programs
attempted to address all of them.
Do CDC and GAO Agree?
At one point, GAO said that CDC had agreed that there was no
evidence that cost was a barrier to immunization. Senator
Packwood followed up on this point aggressively, asking who GAO
spoke with and that they come to the table the persons involved
were not at the hearing. The chairman continued to press until
Dr. Satcher noted that while CDC staff might have agreed that a
particular study did not provide evidence that cost was a barrier,
that was not a conclusion on the general importance of cost. Sen.
Packwood let it go at that.
Sen Packwood If Cost is a Barrier, Why Are Some Immunization
Rates High?
Sen. Packwood noted that immunization rates for three doses of DTP
are much higher (20 percentage points) than for those for four
doses, and asked why. Dr. Satcher argued that parents forgot
their appointments for the fourth shot, which occurred later in
the baby's life. Sen. Packwood asked if cost wasn't a barrier to
the first three doses, why was it a barrier for the fourth? CDC
reiterated that cost was a barrier, among several others. Sen.
Packwood asked if cost was a barrier to immunization for
preschoolers, whose immunization rates are around 95%. Dr.
Satcher said he could not comment on why parents immunized
children at five rather than two, but that it was important for
health reasons to immunize two-year olds.
Sens. Braun and Breaux: Vaccination Saves Money, Focus on Costs
Avoided
Sen. Mosely-Braun said it was difficult to document savings, but
asked that CDC provide information about the amount of money saved
by not having to react to disease outbreaks that were avoided by
proper immunization. Dr. Satcher said the World Health
Organization estimated eradicating polio would save $3 billion
annually, and that polio eradication would save the U.S. $230
million a year. He said numerous studies showed the
cost-effectiveness of vaccinations. Sen. Mosely-Braun said that
it was important to remember these savings when discussing cost
and immunizations.
Sen. Breaux agreed, and said that the focus should not be on cost
as a determinant of immunization rates but on the cost of not
immunizing children. He asked CDC what the cost would be if VFC
had not immunized children, and how many children VFC had
immunized that would not have otherwise been immunized. CDC
replied that it was impossible to know that number, and Sen.
Packwood interrupted to note that as the program had begun only
seven months ago it was hard to judge its impact yet.
Sen Moynihan: Why Involve the Feds?
Senator Moynihan said as the Congress worked on $500 billion in
deficit reduction in 1993, the Administration said that it needed
a new entitlement for vaccinations. This surprised him, as New
York already had free vaccine, and Rostenkowski told him Chicago
had it too, and he didn't understand why the Federal government
would involve itself in something the municipalities had been
doing for a century. He said he hoped we would get away from
simple answers to complex behavioral problems. Dr. Satcher said
that CDC was also trying to address behavioral issues with its
educational campaigns and efforts to improve access to clinics and
tracking systems.
Sen. Simpson: Do People Fear Needles?
Sen. Simpson suggested that low immunization rates in inner cities
were caused by an association of needles not with medicines but
with drugs. CDC staff replied that studies showed that only a
very small percentage of parents don't want their children
immunized, and that most of those cited religious reasons. He
also noted that he had not come across such a perception in his
work in clinics.
Other Witnesses
State health officials and the president of the Children's Health
Fund criticized the program for offering free vaccination to
children with health insurance but without coverage for
vaccination only in Federally Qualified Health Centers. They said
these are not always convenient. A State health official from
Mississippi suggested rethinking the program and letting the
States have more latitude, but the others said the program should
be left as is and its problems fixed.
Distribution:
TO:
Nancy-Ann E. Min
CC:
James I. Blount
CC:
Barry T. Clendenin
CC:
Richard J. Turman
CC:
Mark E. Miller
CC:
Robert A. Allison
CC:
Barbara E. Washington
CC:
William G. White
CC:
Thomas M. Reilly
EXECUTIVE OFFICE OF THE PRESIDENT
May- 1995 03:24pm
TO:
Gordon P. Agress
FROM:
William L. Dorotinsky
Office of Mgmt and Budget, HD
SUBJECT:
VACCINE PROGRAM FACES PROBLEMS OF MISSED OPPORTUNITIES
Date: 05/04/95 Time: 14:31
Vaccine Program Faces Problems of Missed Opportunities
WASHINGTON (AP) As many as 2 million American children under
the age of 2 don't have all the vaccinations they need because of
problems ranging from missed opportunities at the doctor's office
to inadequate services for the poor, experts told a Senate panel on
Thursday.
Even with the 7-month-old government Vaccine For Children
Program, which provides free vaccines for uninsured, underinsured,
Medicaid-eligible, and some minorities, many children still fall
through the cracks, said Dr. David Satcher, director of the Centers
For Disease Control and Prevention.
Dr. F.E. Thompson Jr. of the Mississippi Health Department told
the Senate Finance Committee that physicians often do not check on
whether their young patients have been vaccinated.
'A policy of stick 'em while you got 'em is critical,
Thompson said.
Finding ways to track the children in their complicated
schedules of immunizations is key, said Thompson, whose state just
set up a computerized tracking system.
Many unimmunized children are the nation's very poorest. Often
no one knows they don't have the shots since they have no central
place where all their health care needs are met, said Dr. Irwin
Redlener, president of the Children's Health Fund, a foundation
which tries to establish comprehensive pediatric programs for some
of the nation's neediest.
' 'These kids that we're dealing with are sick, they're
extraordinarily disadvantaged, they're suffering terribly and they
are not immunized,' said Redlener.
'`The kind of health care we're interested in for children is a
comprehensive, continuity-based, organized system where the health
provider becomes the medical home'' for the child, Redlener said.
The government vaccine program will help, the health officials
said. But there is one key problem: Underinsured children whose
families have insurance that doesn't cover immunization are
required under the program to go to specific federally qualified
health clinics, not their own doctors or state health departments.
Such clinics 'are generally located in poor, inner-city or
rural areas, relatively inaccessible to the large percentage of
middle-class families that will fall into this category, said
David Wood, a pediatrician practicing in an inner-city clinic in
Los Angeles.
Thompson suggested the panel rethink the entire government
program, and consider letting the states arrange vaccines
themselves.
But others said the program must stay, just with glitches fixed.
'Our job now is to make the adjustments in an important program
that will permit it to function with maximal impact and in the
spirit intended by its original drafters,' said Redlener.
APNP-05-04-95 1432EDT
05/04/93
18:21
212 535 7488
CHF
001
The Children's Health Fund
Board of Directors
twin Rediener, MC
For Founder. Presulent
'aul Sumon
Co-Farmer
Robert F. Termenhauser, Eaq.
Chairman
jeffrey a Maurer, Esq.
Tre
"
Karch B. Rediener
Secretary
FAX TRANSMITTAL SHEET
Ann Druyan
Freel Francis
Steven I. Green
Dan Klores
Robert C Octorne
Marvin S. Posen
Ray Schulte
Nancy Waldbaum
TO:
Pam Cicetti
Corporate Council
Robert Essner
Chairmen
US.50 John D. Rockefeller IV
Honorary Co-Cluirman
FROM:
Irwin Rediener, MD
U.S. Rep. Sherward L Boehier
t
any (Pustee
fall Barad
Taul Blake. MD
joe Boyd
Cordon Douglas, Tr.. MD
Thomas Kalinske
Shella Leatherman
FAX #: (202) 456-2898 1715
(
1 M. Levin
William M. Lowry
James W. McLane
Don Panoz
Ronald I. Saldarias PhD
H
Shikata
Robert Wellach
DATE:
5/4/95
David Williams
Advisory Board
Paul Signon
Charman
6
Ron Anderson, MD
Number of pages including cover sheet:
Ron Gerger
U.S. Sen Bill Brodley
Net drawn
Michael 1. Cohen, MD
Hon. David N. Dinkins
U.S. Sen Christopher Dadd
Esther R Dyer
Dick Ebersol
If there is any problem regarding this transmittal,
Patrick Ewing
Zachary Fisher
please call Kathryn Sanders at 212-535-9707. Thank you.
Herbert B. Fixler. Esq.
Spencer Foreman. MD
H. fack Gelger. MD
Rod Gilbert
Paul ^ Goldner
Robert J. Haggerty. MD
Dave Herman
Samuel A Keesal Ir., Ear-
Additional comments:
joel Lamstein
Don Mattingly
jewell Jackson MrC abe
will Mcintosh
Paul Metseless
Hon George J. Mitcheil
Pam- a wt- please clute
Billie Heller Monness
jane Pauley
Steven Ricchetti
US. Sen. john D. Rockefeller IV
Carl Sagan
Susan Saint James
pass Thank on to mm.
Susan Taylor
Carry Trudeau
Joseph W. Westhammer, MD
Ronzid Wolfeang
Bert (abroto due
The Children's Health Fund
317 East 64th Street
New York, New York 10021
Telephone 212-535-9400
FAX 212-535-7488
05/04/95
18:22
212 535 7488
CHF
002
The Children's Health Fund
Board of Directors
May 4, 1995
inwin Redlerer. MD
Co-Founder President
i'au. 30 in
First Lady Hillary Rodham Clinton
Co-Founder
The White House
Fribert F. Tannenhauser. Esc.
Washington, DC 20500
leffrey 5 Maurer. Esq.
Treasurer
Dear Hillary:
Karen B. Reciener
Secretary
ABP Druyan
I hope this finds you well. I look forward to seeing you later this month.
Free Francis
Steven y. Green
Than Kicres
Robert C. Osborne
This morning 1 had an opportunity to testify before the Senate Finance Committee
Marvin S. Rosen
Ray --crulte
on the Vaccine for Children program. This has been a difficult issue for me on
Nancy Waldbaum
a number of levels which I have shared with Donna Shalala, her staff and others.
Corporate Council
I have been, as constructively as possible, trying to clarify my own perspective
Robert Essner
Chairman
on immunization which differs from the current operational perspective of VFC.
L.S. Ser John D Rocketeller 1V
Honorary Co-Chauman
In essence, while the cost of vaccine may be a problem for some working-poor
U.S Rep Sherwood T. Bochlers
Honorary Trustee
families, the more intractable issues around underimmunization have to do with
Jitt Barad
the millions of children who do not have a medical home or any regular source
Paul Blake, MO
lee Boyd
of health care where immunizations can be administered and tracked. I testified
Cordon Douglas Jr.. MD
Thomas Kihaske
before Senator Packwood's committee as a strong supporter of the VFC, but in
Sheris Leatherman
Gentid M. Levin
a modified form with several key changes which I believe are essential.
William M Lawry
fame W. Melane
Dun Pance
Ronald) Soldarial. PhD
By the way, my written testimony had already received fairly negative feedback
Hiroshi Snikata
Enbert Wallach
from folks in the administration; and, ironically a very negative reaction from
David Williams
some of our very large funders within the vaccine manufacturing industry. My
Advisory Board
assessment of the hearing was that Senator Packwood-and others--are looking to
Paul Sumon
Chairman
take VFC down for a variety of reasons, not the least of which is plain old
Ron Anderson. MD
politics.
For Berger
0.5. sen. Bill Bradley
Neil Brawn
Michael !. Cohen MD
What I am concerned about, however, is that there is a legitimate case to be made
Hon. David N. Dinkins
L.S. Sen. Christopher J. Hodd
for de-emphasizing the focus on vaccine purchase. There ought to be a
Estner R_ Dyer
Dick Eberson
redirecting of resources toward solving some of the more challenging aspects of
interek Ewing
Zachery Fisher
ensuring a medical home for children who are profoundly medically underserved
Herber 14. Fixter. Esq.
Spencer Foreman, MD
and at greatest risk for underimmunization.
-. jack Geiger MD
End Cilbert
Facil A. Goldner
Knbert T. Haggerty. MD
Here's my strategic suggestion:
Date Herman
Sampel A. Keesai, Jr., Enq.
|oel Lambrein
Don Mattingly
I think the administration should declare a victory in "Phase I" of the VFC
lewed Jackson McCabe
Bill Melntosn
program. In many cases, the availability of subsidized vaccine has helped
Pau: Mememar
Han 500mgr 1. Miachell
families for whom affordability was a problem. We should now move to "Phase
Sillie Heller Monnees
Jane Fauley
II" of the VFC program which would:
Steven Ricchend
US Sen. John D. Rocketeller IV
Carl Sagar
Susan Saint James
move more VFC money to infrastructure and resource
Super Tavior
Garry Trudena
development;
Joseph W. Werthammer, MD
Ronald Wolfgang
The Children's Health Fund
317 East 64th Street
New York, New York 10021
Telephone 212-535-9400
FAX 212-535-7488
05/04/95
18:26
212 535 7488
CHF
003
First Lady Hillary Rodham Clinton
May 4, 1995
Page Two.
suggest that states devise ways to require all family
health insurance policies to cover recommended
childhood vaccines;
attempt to close loopholes which currently permit states
to use public resources for supplying vaccine to
insured or well- off families; and,
encourage and support innovative ways of really
reaching underserved populations.
Such a "Phase II" approach could have a number of major beneficial results. For
one thing, we would really begin maximizing resources to get to the kids who
most need assistance. In addition, it would pre-emptively neutralize the biggest
and most legitimate argument made by opponents of VFC. Finally, it would put
the administration out front on this issue.
I would be happy to provide you with some additional information on this matter.
Perhaps a "Phase II" approach would be helpful in cooling things down, moving
the program forward and gaining some new allies in the process.
Best regards,
Irwin Redlener, MD
IR: kms
enclosure
The Children's Health Fund 317 East 64th Street New York, New York 10021 Telephone 212-535-9400 FAX 212-535-7488
05/04/95
18:26
212 535 7488
CHF
004
The Children's Health Fund
Board of Directors
Paul Simon
March 24, 1995
Co-Former
Irwin Redlemer, MD
Co-Fourster, Presicant
Robert F. Tannenneuser. Exq.
The Honorable Donna E. Shalala
Chairman
Jeffrey 5. Maurer Esc.
Secretary
Treasurer
Department of Health and Human Services
Karen B. Reciener
Secretary
200 Independence Avenue, S.W.
Ann Druyan
Washington, D.C. 20201
Fred Francis
Steven T. Green
Dan Klores
Robert C. Orborne
Dear Secretary Shalala:
Marvin 5. Rosen
Ray Schule
Name Waldbaum
Corporate Council
It was good to see you earlier this week at the White House. I want to
David R. Bethune
take this opportunity to review our position on national immunization
Chairman
strategies.
Senator John D. Rocketeller IV
Honorary Cr-Chairmen
Senator Christopher 9. Bond
My observations and concerns on this matter in general and the VFC
Febrary Co-Chairman
program in particular are based on nearly 25 years of experience in
Joe Boyd
Robert Essae
Gordon Dougles. J=., MD
caring for some of the most disadvantaged and medically underserved
Edward V. Fritzky
Thomas Kalinske
children in the country. At this time, we are running the country's
Gerald M. Levir.
James W. McLe.«
largest health care program for homeless children here in New York, in
Don Fanoz
Romald Saldarini, FaD
addition to intensive medical services for children in South Central LA,
Hirosh! Shikats
Robert Wallach
Anacostia in D.C., south Florida, Newark, rural Mississippi, West
David Williams
Virginia, Dallas and the South Bronx.
Advisory Board
Foul Simon
Chainan
Immunization status in children is, of course, a determinant of
Ren And orson, MD
Bon Herger
vulnerability to vaccine preventable disease. But from the public health
Senator SUI Bradlev
Noil Braun
and policy perspectives, immunization status is one of the better markers
Michael 1. Cohen, MD
Hon. David N Thakins
of accessibility to good quality primary care in children. This is a key
Senator Christopher i. Doda
Esther P. Over
concept: children who have "medical home" type comprehensive,
Dick Chersol
H incrable Mike Espy
continuity-driven health care have an excellent chance of being up to date
Patrick Ewing
Zachary Fisher
in their immunization schedule.
Herbert B. Fixler. Esn
Spencer Foreman, MD
H. jack Geiger. MD
Rod Gilbert
Pri A. Coldner
Conversely, the most important reason why millions of children are
Robert 5. Haggerry. MD
Dave Herman
behind in their immunizations, from my point of view, is that they do
Gioria Janata
Samuel A. Kensal, fr., Esq
not have a regular source of medical home type pediatric care. Isolated,
juei Lamstein
Con Mettingly
categorical programs to vaccinate children without attending to their
lewell Jackson McCabe
Eill Mcintesh
source of on-going care problems either (1) fail to provide a way of
caus Metsclaar
Genator Grange Mitchell
sustaining immunization levels or (2) do not reach the most vulnerable
Billie Heller Monners
Jane Cauley
Steven Riechert
and intractably unimmunized populations.
Senater John D. Rocketeller rv
15agan
Susan Saint James
Susan Taylor
joseph W. Werthammer, MD
Senator Hams Wofford
Ronald Wollgans
The Children's Health Fund
317 East 64th Street
New York, New York 10021
Telephone 212-535-9400
FAX 212-535-7488
05/04/95
18:27
212 535 7488
CHF
005
The Honorable Donna E. Shalala
March 24, 1995
Page Two.
I have been arguing this point for years with many people in
government, including my friend Walter Orenstein at the CDC. Isolated
immunization programs may actually reduce the incentive for parents to
identify and utilize a pediatric medical home for their children, thus
depriving those kids of a variety of other necessary health care services.
The VFC program is a concept which has become, in my judgement,
increasingly irrelevant to the extracrdinary needs of children most likely
to be partially or totally unimmunized. The VFC program does nothing
for my patients who, until they get into a medical home relationship,
have as much as a 90% chance of being behind in their shots. This is
true for homeless kids in New York and children living in rural isolation
and poverty in the Mississippi delta.
VFC helps parents who are, for the most part, already in private
pediatric practices, but without insurance coverage for vaccines. What
does the program do for the five to ten million children who simply have
no doctor? These are the children about whom I am most desperately
worried.
My point is that if we have money to improve immunization rates, let's
use as much of that as possible to give children access to complete health
services. It is health care, not vaccines, that should be guaranteed for
children by government.
Many states are taking advantage of provisions in the VFC program, and
are doing so in ways which represent a gold mine for insurance
companies. The latter are "off the hook" in terms of covering vaccine
since it will simply be paid for by the government, irrespective of family
financial status.
Donna, I am deeply worried that VFC is a program in trouble. Some of
the criticism is legitimate: some is politically driven and dangerous. I
think, however, that the program can be fixed to do what was intended
without some of the flaws currently inherent in its design.
The Children's Health Fund
317 East 64th Street
New York New York 10021
Telephone 212-535-9400
FAX 212-535-7488
05/04/95
18:27
212 535 7488
CHF
006
The Honorable Donna E. Shalala
March 24, 1995
Page Three.
I am hoping that our meetings with you and/or your staff will allow us to
suggest some possible mechanisms to fix VFC in ways that will keep all
of us who care about children on the same wavelength.
Sincerely,
Die Irwin Redlener, MD
Associate Professor of Pediatrics
Albert Einstein College of Medicine
- Montefiore Medical Center
The Children's Health Fund 317 East 64th Street New York, New York 10021 Telephone 212-535-9400 FAX 212-535-7488
MAY-01-1995 08:11 FROM
TO
91567028 P.01
NUMAN Stavices USA
DEPARTMENT OF HEALTH & HUMAN SERVICES
Chief of Staff
HEALTH
Washington D.C. 20201
:
FACSIMILE
DATE 5/4
TO:
(NAMF, ORGANIZATION. CITY/STATE AND PHONE NUMBER) :
gen- works like
Diana Fortuna
FROM:
(NAME, ORGANIZATION, CITY/STATE AND PHONE NUMBER) : S is
Melissa
the case-
on
Cream pa, 2.
Jii Hargis
Diana
RECIPIENTS FAX NUMBER: ( ) 4567028
NUMBER OF PAGES TO SEND (INCLUDING COVER SHEET) :
9
COMMENTS.
MAY-01-1995 08:11 FROM
TO
91567028 P.02
Kerm-
5/3
NOTE TO JAKE SIEWERT --
As discussed, Dr. Satcher and Dr. Orenstein will be testifying on
the VFC program tomorrow -- I'm planning to wrote up some talking
points after we get final clearance on their remarks from OMB.
In the meantime, I've attached some "generic" VFC talking points,
and some of the supportive letters we've solicited from the
American Academy of Pediatrics and the March of Dimes. We plan
to distribute these to reporters tomorrow, along with the
testimony and the child immunization fact sneet.
Please share these with Ginny, and let me know if you need
anything else.
Melissa
MAY-01-1995 08:11 FROM
TO
91567028 P.03
Talking points - Vaccines for Children
The Vaccines for Children program is as important part of the
broader Childhood Immunization Initiative. The CII includes five
key strategies to improve preschool vaccination rates. These
include improving the quality and quantity of vaccination delivery
services; reducing vaccine costs; increasing awareness, community
participation and partnerships; improving the monitoring of disease
and vaccination coverage; and improving vaccines and vaccine use.
Improving preschool immunisation rates is one of the Clinton
Administration's highest priorities. since taking office, the
Clinton Administration has doubled funding, and guaranteed funds
for new vaccines. Legislation to launch a new Childhood
Immunization Initiative was introduced soon after President
Clinton's inauguration. A specific goal was set for 1996:
increasing vaccination levels for two-year-old children to 90
percent for the most critical doses. And a new program LO provide
free vaccines to millions of poor and uninsured children was
instituted.
While child immunisation rates have improved since the 1989-1991
measles epidemic, VFC is a key part of the national strategy to
reach the one million American children who are not fully
vaccinated by age two. A 1993 survey found that 33 percent of
pre-school children (average age 27 months) had not received a full
series of the three most critical vaccines (MMR, DTP and polio).
About 45 percent had not received the HIB vaccine, which protects
children against bacterial meningitis; and 84 percent had not been
vaccinated against Hepatitis B, which causes liver disease.
As an integral part of the CII, the Vaccines for Children program
focuses on making free vaccines more widely available, reducing
costs and missed opportunities for immunisation. In the past ten
years, immunization costs have increased ten-fold: the private cost
of a full series of immunizations increased from about $27 in 1983
to $270 in 1994. A Spring 1992 survey by the American Academy of
Pediatrics showed that 43 percent of pediatricians had increased
their referrals to public clinics for vaccinations in the preceding
ten years, primarily because of costs.
Under the VFC program, vaccines will be provided free to children
who are enrolled in Medicaid or uninsured, and to native Americans
and Alaskan natives. That moans that physicians will no longer have
to refer uninsured children to public clinics, a common practice
that means missed opportunities for immunizations and fragmented
care. And parents can choose which provider makes the most sense
for their child, because the difference in price between the two
settings ($270 and $129) won't be a factor.
MAY-01-1995 08:15 FROM
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94567028 P.01
This will make a tremendous difference for nine million uninsured
American children. While Medicaid rccipients can receive free
vaccines under current law, working families have not had the same
guarantee. Under VFC, more than one million infants and toddlers
without insurance will now be guaranteed free vaccines, and their
parents will pay only a modest administration fee. And because ten
percent of all American children don't have health insurance, VFC
will also help millions more older children who need follow-up
vaccines at age four and fifteen.
Under VFC, every eligible child will receive vaccinations, even if
parents cannot afford to pay the administration fee. Private
doctors will continue to serve their regular patients, even if the
parent or guardian cannot afford to pay the administration fee.
Other needy children will not be charged a fee in public clinics.
In addition, VFC will provide free vaccines to children with
limited insurance in rural health clinics and Federally Qualified
Health Centers. In these settings, additional children whose
insurance plans don't cover vaccinations will continue to be
eligible for free vaccines.
Funds for new vaccines will automatically be provided. Under VFC,
new childhood vaccines recommended by a federal advisory committee
will automatically be purchased by the federal government and
provided free to eligible children -- and budget constrainte will
never again limit or delay federal purchase of new vaccines.
States will be able to save money by ordering vaccines at the
lower, government price. Because VFC will lower states' Medicaid
costs for vaccines, these savings can be used to keep clinics open
longer, or take other measures to increase immunization rates. And
more states will be guaranteed the lower CDC price for the vaccines
they do purchase.
Child immunization protects children and saves money. For example,
every dollar spent on the MMR (measles/mumps/rubella) vaccine saves
$21 in potential health care costs. For the DTP (diphtheria/
tetanus/pertussis) vaccine, the cost-benefit ratio is 30 to 1. And
for polio, it's 6 to 1.
MAY-01-1995 08:16 FROM
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MAY BS '95 12:55 FR MARCH OF DIMES DC 202 296 2964 TO 6908168
P.04
Marchet
Thanks
March of
Sire Defects Feundation
National Government Affairs Office
1901 L Street N.W., Suice 300
Washington DO 20036
Telephone 202 - 1800
FAX 802 as 2084
May 3 1995
The Honorable Bob Packwood, Chairman
Committee on Finance
United States Senate
219 Dirksen Senate Office Building
Washington, DC 20510
Dear Mr. Chairman:
It is my understanding that the U.S. Congress is reviewing the effectiveness of the
Vaccines for Children Program. The March of Dimes has particular interest in this
program because our mission is to improve the health of babies by preventing birth
defects and infant mortality. Timely childhood Immunizations can do both Our history
includes efforts to prevent polio, as well as to climinate rubella and the serious birth
defect congenital rubella syndrome. We also believe no babies should die of measles
as many did in the 1990-91 epidemic.
When fully implemented, the Vaccines for Children Program would ensure that
poor and uninsured children have financial access to all necessary vaccines. While rates
of childhood immunization for individual vaccines have improved over the last few years,
only two-thirds of children are fully immunized (4 DTP, 3 polio and 1 MMR) by their
second birthday.
The Federal childhood vaccine program funded through appropriations for local
health departments has long fallen short of the need. For example, before the Vaccines
for Children Program was initisted, the federal distribution for the Hib meningitis vaccine
was inadequate for three years after it was put on the market Health departments had
to ration the vaccine, rather than protect all children
The shortfall in public funds was related to steady increases in the price of
vaccines. At the same time, many uninsured working families paid double the public
price for vaccines in private physicians offices. When they could not afford these prices,
such families were sent to the already burdened health department clinics. The Vaccines
for Children Program can help families acceive affordable immunization services from
their private pediatricians.
FROM 202-296-2964
05-03-95 12:45 PM
MAY-01-1995 08:16 FROM
TO
91567028 P.06
MAY 03 '95 12:56 FR MARCH OF DIMES DC 203 296 2864 TO 6908168
P.O.
The Vaccines for Children Program can both save money for federal and state
government and target needed immunizations to children who are uninsured and whose
families cannot afford the out of pocket costs for vaccines. The Vaccines for Children
Program provides relief to states, who can reallocate public health dollars for outreach,
education and services. The federal law also correctly protects states' rights to purchase
vaccines for all children at the Federal price.
It is important to remember that the Vaccines for Children Program was
developed as a bipartisan compromise, including elements from the original Clinton
Administration plan, as well as from hills introduced by Democratic and Republican
Senators in the 103rd Congress (S.733 and S.732 introduced by Senators Reigle and
Kennedy; and S,886 introduced by Senators Danforth, Kassebaum, Durenberger, Gregg
and Bond).
As president of the March of Dimes, I urge you to work for continuation of the
Vaccines for Children Program so that the goal of immunizing all our nation's children
with age-appropriate vaccines can be reached by the Year 2000.
Sincerely,
Semala HOUSE
Dr. Jennifer L Howse
President
FROM 202-296-2964
05-03-95 12:45 PM
205
MAY-04-1995 08:18 FROM
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94567028 P.08
PANE 2
American
Academy of
Pediatrics
May 1, 1995
David Satcher, M.D.
Director, Centers for Disease Control and Prevention
1600 Clifton Road, NE
Atlanta. GA 30333
Department of Government
Listeon
American Academy of Pediatrics
Dear Dr. Satcher:
The Homer Building
601 Thirlsents Street, NW
Suite 400 Nonh
The American Academy of Pediatrics, and, more importantly, the families
Washington, DC 20006
202/547-8800
we serve, urge your continued support for the Vaccine for Children
600/336-5475
(VFC) Program. Although the program * only in as infancy (8 months)
Fax 202/323-6137
and has had more than its share of growing pains, over 36 states have a
complete program, with the remaining in various stages of development.
Unril all children and adolescents have financial access to comprehensive
health care, the VFC program provides an important remedy for obstacles to
our nation's immunization initiative in 4 important areas:
1) it provides immunizations for the increasing number of children in
working middle-class families where dependent coverage is either not
covered or dropped;
2) it assures that all eligible children will receive the benefits of
President
George D. Comerci. MD
newly recommended vaccines for school entry. thus strengthening
immunity levels of the contimunity;
Vice President
Maurica E. Kaenan, MD
3) it gives states the option to purchase additional vaccines B cover
Past President
the so-called underlasured children who have typical insurance
Batty A. Lowe, MD
policies which don't include immuntizations; and
Exacutive Director
4) it allows Medicaid and native American families to receive
Joe M. Sanders, Jr. MD
immunizations in $ medical home.
Beard of Directors
Global L Futd. MO
The VFC Program is an integral part of this nation's goal of protecting its
Keene, New Hampshire
youngest citizens from the ravages of vacine-preventable diseases. It must
Louis 2. Cooper, MD
be viewed within the context of all other public and private health initiatives,
New York. New York
each contributing an important element. A premature hall to the VFC
Susan Aronson. MD
Narbonh, Pennsylvania
Program in the absence of universal access to health care including
Joseph R. Zanga MO
immunizations, would leave many children in limbo and vulnerable to
Nichrond, Vegints
disease.
Robert E. Harnsmann. MD
Lalayette. Indiana
Themes F. Temigee. MO
The VFC Program is deserving of your support.
Hastings. Nebranks
Carden Johnston, MD
Sincerely yours,
Blemingham. Alabama
Donard E. Cool MD
Years D Comerce 1m0
Greetey. Calorado
George D. Comerci, M.D.
Leonard A, Kumik, MD
San Ciago. Callfornia
President
The American Academy of Padiatrics is committed to the attenment of opainel physical,
mental, and societ health for all Inland chadren, edoleacents, and young adults.
94567028
P.07
TO
MAY-04-1995 08:17
FROM
FILE No. 288 05/03 °95 13:03 ID:AMER.ACADEMY PEDS.
202 393 6137
PAGE 2
American
Academy of
Pediatrics
601 Thirmanch Suan. N.W.
Suize 400 Nonh
News Release
Washington. DC 20005
CONTACT: Marjorie Tharp
FOR RELEASE:
May 3, 1995
800/336-5475
202/347-8600
BUDGET PROCESS THREATENS VACCINE PROGRAM
Washington. D.C. -- The American Academy of Pediatrics (AAP) is urging Congress to
maintain federal funding for the Vaccines for Children (VFC) program, which provides free
vaccine to children meeting certain requirements.
"Americans want fiscal responsibility," AAP President George Comerci, M.D., said, "and in
this case, the economic sense comes from investing money in a preventive service now to
avoid higher health care costs later."
The Senate Finance Committee will review the VFC program tomorrow, 9:30 a.m., 215
Dirksen, to determine whether funding should be cut or eliminated so that the savings can be
used towards balancing the budget.
The VFC program, just 8 months old, guarantees free vaccine to children age 18 or younger
who are Medicaid eligible, uninsured or Native American. Underinsured children are eligible
if they receive care at a federally qualified health center.
According to the AAP, the VFC program addresses most of the barriers some parents faced in
delaying their child's immunizations, such as:
offering free immunizations for children in working, middle-class families
where dependent coverage is either not included or has been dropped;
-more-
FILE No. 288 05/03 '95 13:04 ID:AMER. ACADEMY PEDS.
1
202 393 6137
PAGE 3
VFC PROGRAM
2-2-2
providing states the option to purchase additional vaccines at a reduced
price to cover underinsured children whose insurance doesn't include
immunizations;
allowing Medicaid and Native American families to receive immunizations
in a medical home.
assuring that all eligible children will receive the benefits of newly
recommended vaccines for school entry, causing immunity levels in the
community to strengthen.
"The truth is that medical science has done such a fantastic job of virtually eliminating these
infectious diseasos," Dr. Comerci said. "People have forgotten what it was like when
diphtheria, polio and other contagious diseases were common.
"Clearly, vaccine manufacturers have shared in this success story. We must ensure that they
are able to continue their research and development of new and better vaccines.
"But make no doubt about it, we still need the government's financial support for the VFC
program in guarantee that our children, and subsequently the communities they live in, are
free of preventable diseases.
"Immunizing children is a public health issue. Until all children and adolescents have
financial access to comprehensive health care, the VFC program must remain intact."
The VFC program was appropriated $348 million for fiscal year 1995. President Clinton's
fiscal year 1996 budget proposes $365 million
###
the The health, American safety deademy US rediarrics is an organization of 19.000 dedicated 10
The
George
Washington
University WASHINGTON DC
CENTER FOR HEALTH POLICY RESEARCH
May 4. 1995
The Honorable John D. (Jay) Rockefeller IV
United States Senate
Dear Senator Rockefeller,
We are writing in response to your request for further information about our recent study.
Universal Childhood Vaccine Distribution: The Experience of Twelve States. This study is the first
comprehensive study of state universal vaccine distribution programs. It analyzes the 12 state
universal pediatric vaccine procurement and distribution programs which were in effect during the
1993-94 time period.¹ The study has been cited by Dr. Irwin Redlener in testimony prepared for the
Senate Finance Committee's hearing today on the Vaccines for Children (VFC) program. In his
testimony Dr. Redlener states that our study "verifies" that the "VFC in its current form does not
confront the factors responsible for severe under-immunization in the millions of children who have
no regular source of care".
We would like to take this opportunity to clarify our findings. We request that both this letter
and the full study (a summary version of which was sent to more than 250 state policy makers) be
included in today's hearing record.
Study findings. As part of the study we conducted extensive interviews with state officials
responsible for the administration of their state's childhood immunization programs. We found as
follows:
As Dr. Redlener notes, virtually all states with universal vaccine procurement and distribution
programs continue to report barriers to childhood immunization that arise from factors other
than the lack of availability of low cost vaccine. The only exception is Vermont, which has
been able to provide a medical care home to nearly all children. Officials in that state reported
that because vaccines are distributed free of charge to all pediatric providers, children are
routinely immunized as part of their ongoing health care. Data available at the time our study
showed that Vermont had the highest rate of childhood immunization among the universal
states.
I
Of the 12 states with universal programs that we studied. four are represented on the Finance Committee (Rhode Island.
Wyoming. South Dakota and Alaska). Additionally, since October 1. 1994. five states and the Commonwealth of Puerto Rico
have instituted universal vaccine purchasing and distribution systems. Of these. two (North Dakota and Illinois) are represented
on the Finance Committee
2021 K STREET. N.W., SUITE 800
WASHINGTON, DC 20052
(202) 296-6922
FAX (202) 785-0114
However, state officials also uniformly reported that the universal availability of free vaccine
was an essential component of their childhood immunization improvement efforts
(Rosenbaum and Wehr, p. 73). Officials considered the availability of free vaccines to both
publicly funded and office-based providers as a basic building block for all state pediatric
immunization improvement efforts. State initiatives include both the expansion of the public
administration infrastructure for children without health care homes, as well as efforts to
improve the performance of office-based primary care providers in order to reduce the
problem of "missed opportunities" According to the officials whom we interviewed, the
problem of "missed opportunities" emerged as second most commonly reported barrier after
inadequate pediatric primary care services for underserved children (Appendix 16, table 12).
It is our understanding that the fundamental purpose of the VFC program is to ensure that
in all states there is a sufficient supply of affordable vaccine at least for Medicaid-enrolled, uninsured,
Indian, and medically underserved children cared for at rural and urban health clinics. In this sense,
the VFC program acts as a companion to other federal immunization initiatives including initiatives
to improve infrastructure which are carried out by the CDC with appropriated funds. Were VFC
funds to be reduced or eliminated, it would appear that the CDC would be forced to withdraw some
or most funding for infrastructure improvements in order to once again buy vaccines for many of
these children.
The task of improving childhood immunization levels a three-part undertaking. All three parts
are of equal importance. One part is ensuring the availability of a sufficient and stable vaccine
supply. Another is improving vaccination practices among providers. According to national
statistics provide half of all care received by low income children is furnished by office-based
physicians. The final task is the development of a strong publicly funded preventive health care
infrastructure for children without a health care home. We believe that all three activities are
essential. Given the enormous cost-effectiveness of pediatric immunization according to innumerable
studies, we would recommend that the nation invest in all three legs.
Sincerely,
CM Sara Rosenbaum
Elish well
Elizabeth Wehr
Co-Director
Research Associate
cc: The Honorable Bob Packwood
The Honorable Daniel Patrick Moynihan
MAY-04-1995 09:13 FROM
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STATEMENT
PRESENTED BY
LLOYD F. NOVICE, M.D., M.P.H.
FIRST DEPUTY COMMISSIONER
NEW YORK STATE DEPARTMENT OF HEALTH
HEARING BEFORE
THE SENATE FINANCE COMMITTEE
UNITED STATES SENATE
ON
THE VACCINES FOR CHILDREN PROGRAM
THURSDAY, MAY 4, 1995
ROOM 215
DIRKSEN SENATE OFFICE BUILDING
WASHINGTON, D.C.
MAY-04-1995 09:13 FROM
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Statement by Lloyd F. Novick M.D., M.P.H., First Deputy
Commissioner, New York State Department of Health.
Good morning. My name is Lloyd Novick and I am the First
Deputy Commissioner of the New York State Department of Health.
I am here on behalf of Dr. Barbara DeBuono, Commissioner, New
York State Department of Health. who serves on the Advisory
Committee on Immunization Practices to the United States Public
Health Service I am pleased to have the opportunity today to
present to the Committee New York's experience with the Vaccines
for Children program (VFC). Since its inception a little over
six months ago, VFC has become an important link in the chain of
our efforts in New York to improve the vaccination status of our
children and. ultimately, to prevent unnecessary illness and
death in these, our most vulnerable citizens.
We at the state level have designed a unique system which
successfully serves children in New York. In our state, we have
invented a vaccine distribution system which allows children to
be vaccinated by their own pediatrician or family doctor, thus
preserving continuity of care.
States should have the opportunity to design their OWN
programs, and the federal government should continue to support
state programs that have demonstrated track records of success.
States can benefit from both federal assistance and flexibility
in the design and implementation of programs of this type. I
strongly recommend to you this morning that you continue to
provide support for immunization of children to achieve our goal
to eliminate vaccine-preventable diseases in this country.
States need both federal assistance and flexibility in the design
and implementation of programs of this type.
In recent years, New York children have suffered because
vaccine preventable diseases were not prevented. In 1990 and
1
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1991. we had the largest measles outbreak in recent memory with
almost 5,000 confirmed cases and 24 deaths. In 1993 and 1994, we
had the highest rates of pertussis, or whooping cough, in over a
decade. The root of the problem is poor vaccination levels in
preschool children. In New York, we have only recently achieved
the level of 58% of two year olds up-to-date for the basic series
of vaccines.
We take a very aggressive approach to childhood vaccination
in New York. We adopted a routine 2-dose measles vaccination
schedule before the rest of the nation. We were among the first
states to require screening of pregnant women for hepatitis B and
treatment of at-risk newborn babies, and we are the first to
require routine hepatitis B immunization for entry into school.
The National Vaccine Advisory Committee's "Measles White
Paper" in 1991 spelled out the barriers to timely preschool
immunization. These run the gamut from educating and motivating
parents to get their children vaccinated and making preventive
health services available, to ensuring that these services are
actually provided including ensuring that vaccines are available.
We will not succeed by removing only one or two of these
barriers; all are critical links in the chain leading to the goal
of full vaccination coverage. In New York, we have aggressively
attacked these barriers on all fronts, as outlined in the
attachments to my testimony.
The focus of many of our efforts to improve vaccination
status is the concept of a "medical home" for each child: a
health care provider who the family can know and trust, and who
is able to provide vaccinations and other preventive health
services.
The Vaccine program is an important link in our efforts to
build a partnership for immunization between public health and
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the medical care community in New York. This partnership is
vital because between two-thirds and three quarters of children
in New York receive their routine medical care in the private and
voluntary sector and not in public health department clinics.
This is in sharp contrast to the situation our colleagues face in
Mississippi and some other states where the vast majority of
vaccinations are given in public health clinics. No amount of
effort directed at the public health clinics in New York will
solve our immunization problems because that is not where most
children are vaccinated.
Despite the problems you may have read about in the
newspaper with the federal VFC vaccine warehouse. New York's VFC
program began on time last October and has grown rapidly into a
major success. We have enrolled over 2,800 physicians and 478
health facilities including 95% of major Medicaid fee-
for-service billers. We have shipped over 2.8 million doses of
vaccine. We have begun a media campaign informing parents of the
program highlighted by a television spot by the Harlem Globe
Trotters.
Have we had problems? That goes without saying in a program
of this magnitude. Overall, there have been remarkably few
problems.
Have physicians embraced the program? The enrollment
numbers speak for themselves. A recent satisfaction survey of 55
enrolled physician practices showed good acceptance of the
program.
Will immunization levels improve as a result of VFC? Again,
I believe the answer is yes, although the impact of VFC will be
hard to separate from that of all of our other efforts.
There are a number of ways that we can already measure the
impact of VFC in New York. First, we view VFC as more than a
3
MAY-04-1995 09:15 FROM
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vaccine distribution program and are already using it to educate
enrolled providers on good vaccination practices. We
have also taken steps to protect VFC vaccines by supplying many
enrolled providers with continuous temperature recording
thermometers. We have also seen a tremendous demand for
hepatitis B vaccine suggesting that VFC has helped to speed
acceptance of this vaccine. Steps like this will be increasingly
important as new vaccines, like the chickenpox vaccine which
requires lower storage temperatures and different handling
practices than other vaccines, are introduced. We are
coordinating VFC with immunization registry development and
should be able to use the registry as an accountability tool in
the future. we have also seen a tremendous demand for hepatitis
B vaccine suggesting that VFC has helped to speed acceptance of
this vaccine for routine use.
Finally. and most significantly, we have preliminary
evidence that referrals for vaccination to public health clinics
have declined dramatically. Data on vaccine usage from the first
37 counties for which they are available indicate an average 30%
drop in vaccine administered in county health department clinics
in December 1994 - February 1995, compared with the same time
period in 1994. If this trend continues and is seen in other
counties, it will provide significant evidence suggesting that
VFC has reduced some referrals to public health department
clinics.
I want to conclude by reiterating our support for federal
immunization assistance in New York. The program is up and
running in New York and is working well as an important link to
improving our commitment to immunization for the sake of our
children's health.
Thank you. and I would be glad to answer any questions.
4
TOTAL P.05
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NEW YORK VACCINES FOR CHILDREN (NY VFC)
STATUS REPORT
APRIL 1995
MAY-04-1995
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NEW YORK VACCINES FOR CHILDREN (NY VFC)
STATUS REPORT - APRIL. 1995
The 1993 Omnibus Budget Reconciliation Act created a new Federal vaccine entitlement
program for children under the age of 19. This program is known as the Vaccines for
Children Program, commonly called VFC. In New York, local funds are used to expand
the program to include other categories of children.
Eligibility
A child meets federal VFC eligibility requirements in one of the following ways:
as a Medicaid recipient,
by not having insurance,
being underinsured and visiting a Federal qualified health center,
being an American Indian/Alaskan native.
New York VFC eligibility includes:
underinsured children in any medical setting other than FQHCs.
nonfederal eligible patients served at a local health department.
Doses Distributed
New York State and New York City implemented NY VFC and began,enrolling
providers in July 1994. On September 15, 1994, NY VFC was distributing vaccine to
participating providers and facilities. Since October 1, 1994, the effective date for the
program, free vaccine has been available to participating physicians and facilities in New
York State for VFC eligible children. From September 15, 1994 NY VFC has shipped
approximately 2.8M doses from the NYC DoH. NYSDoH depots and from the NYSDoH
contracted distribution vendor. Combined federal VFC dollars for New York State and
New York City equal approximately $30.5 million in calendar year 1995.
Provider Enrollment
As of April 27. 1995 a total of 2.836 physicians and 478 facilities have enrolled in the
VFC program. The attached maps show physician and facility enrollment by county. NY
VFC staff compared 1993 Medicaid billing information related to child vaccinations with
our provider information. 2,160 providers billed Medicaid for childhood vaccinations in
1993. Of these billers, 1,482 are currently enrolled in the NY VFC. Of the 163
physicians who billed Medicaid for more than 1,000 immunizations in 1993, 95% are
currently enrolled in NY VFC..
I
MAY-04-1995 09:16
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Patient Eligibility Estimates
In order to enroll in NY VFC each provider must estimate their patient population by
eligibility category. The current summary of the provider profiles estimates of their
patient eligibility status is compared to the statewide VFC eligibility estimates below
Provider Profiles
Statewide Eligibility Estimate
41%
Medicaid recipients
51%
15%
Uninsured
12%
1%
American Indian/Alaskan Native
.3%
1%
Underinsured served at a Federally Qualified Health Center
.3%
13%
Underinsured not federally qualified and served in a public clinic
10%
29%
Fully insured - not covered by VFC.
28%
Recruitment of Providers
NY VFC is recruiting physicians on an on-going basis. The following describe some of
our efforts:
at the request of District II of the AAP and the Preferred Providers and
Children (PPAC) Advisory Committee we developed a question and
answer form to respond to the most commonly expressed concerns about
VFC.
NY VFC recruitment advertisements have been published in professional
newsletters,
a second NY VFC recruitment mailing was sent to 4,034 non enrolled
physicians ( some of which may not be in active primary care practice) in
January 1995,
a mailing will be sent to members of the District II AAP who are not
enrolled in NY VFC.
Consumer Campaign
posters and pamphlets for waiting rooms and consumers are being
distributed to inform consumers of this program.
a public service announcements featuring the Harlem Globetrotters is
being distributed 10 radio and television stations statewide.
VFC and Provider Referral Practices
One of the goals of the VFC Program is to eliminate the need for private physicians and
other providers to refer their patients without adequate health insurance for immunization
10 public clinics. Encouraging the immunization by primary care providers of children in
their "medical home" has been identified as 2 way to substantially reduce the "missed
opportunities" that often result in delays in immunizing children. A random sample
survey of NYS pediatricians and family physicians was conducted in 1993 to determine
vaccination practices. Fifty percent of physicians stated that they referred all or some of
their patients elsewhere for vaccinations. Eighty-eight percent of physicians who referred
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MAY-04-1995 09:17
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patients for vaccinations indicated financial hardship to be a very important reason for
referral. Fifty-four percent of physicians responding to the survey indicated that some or
all of the costs of childhood vaccinations should be underwritten by government. (Refer
to MD survey for referral information). Preliminary data from a number of county public
clinics in New York State indicates that the number of children being referred to their
clinics for immamizations has decreased since the implementation of the program (a
decrease of 45% of vaccines were administered in the 5 public clinics for which we have
data from similar time period BEFORE VFC & AFTER VFC implemented). This trend
is expected to continue, thereby increasing the number of children who are immunized
on time while visiting their primary care physician.
Less than 20% of all two year old children in New York State are served by public
clinics. The vast majority of children are served by the private medical community. It is
clear that the best route to increasing the number of children who are immunized on time
is to forge a public/private partnership to address this issue. Without the active
participation of private sector providers, any effort to improve the immunization levels in
New York State will fall short of it's goal. The New York Vaccines for Children
represents the best hope thus far for achieving an effective partnership in pursuit of our
goal.
Satisfaction Survey
In order to monitor the level of satisfaction with the NY VFC Program we have
developed a survey instrument which is used by Department of Health field staff when
contacting participating providers. This "satisfaction survey" (see attached questionnaire)
enables providers to describe their experiences with the program in a way that will both
help identify aspects of the program that are effective or need to be improved and to ask
physicians if they think the program will help their patients. The most recent survey
conducted included 55 private physicians practices representing 181 individual physicians
and 36 facilities (hospitals and clinics). Of those polled 87% of physicians and 77% of
facilities indicated that the program's vaccine ordering system is convenient to use and a
large majority felt that the operators reached through the toll-free number were
knowledgeable and helpful Survey responders also indicated that vaccines were received
in a timely fashion and in good condition. Significantly, 89% of physicians polled stated
that they felt that the VFC program was beneficial for their patients and 58% concluded
that the enhanced vaccine administration reimbursement through VFC provided an
incentive to serve Medicaid enrolled children. Ongoing use of the survey will allow the
program's administrators to see "how they are doing" and to respond quickly to
participant's problems. Complete results of the most recent survey are represented on the
attached sheet entitled "VFC Satisfaction Survey".
Vaccine Accountability
From the inception of the VPC Program it has been our intention to provide
accountability systems that both represent responsible oversight of public funds and
minimize provider burden. This is in part because State purchased vaccines are also
being distributed in the system for which we need to maintain accountability. The
specific issues that we want to be able to account for are proper vaccine handling to
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minimize waste, appropriate use of specific funds by eligibility criteria and a decrease in
patient referral practices away from the "medical home". The following systems currently
are or will be implemented in New York State to assure VFC accountability:
Pilot State working with CDC to develop accounting problems from doctor's
offices that are not overly burdensome.
Using vaccine ordering records to compare "orders" to "provider profiles" to
determine if profiles should be amended. In most instances providers over
estimated the number of children they serve. Ordering practices can be used to
adjust the profiles.
From aggregated provider profile information determine if patient status
percentages are in accordance with the state population profiles. This has been
done periodically and percentages are in line with previous statewide estimates.
Review vaccine orders to determine that providers are not ordering vaccines in
excess (three month supply) of their patient estimates. Specific vaccines such as
pediatric DT and adult Hep B will have special edits attached to ensure that
vaccines are not used beyond the CDC or NYS established policies.
Periodically cross reference vaccine administration billing information from
Medicaid with vaccine ordering and profile information from the same physician.
Conduct random educational/technical assistance visits to providers to make
available vaccine storage and safeguarding information as well as other pertinent
issues about vaccine scheduling, contraindications, school immunization
requirements etc.
Conduct "spot checks" record reviews among providers whose ordering
patterns/amounts are considered to be outside the norm of other similarly sized
providers.
Conduct periodic random audits of facility providers to review record keeping,
vaccine handling and verification of provider profile information.
Continue annual local health unit visits to review vaccine storage/handling and
implementation of Standards of Pediatric Immunization Practices.
Record instances of vaccine loss by provider name/site. Ensure those sites receive
additional information/tips on vaccine safeguarding. If vaccine loss occurs
frequently, make site visit or remove from NY VFC program.
Determine through phone call or mail survey what vaccine safeguarding
systems/policies are in place in sites where large quantities of vaccines are
4
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maintained As resources permit, provide those sites with temperature monitoring
devices, model protocols,"day-gio"stickers to be placed on outlets and
refrigerator, etc.
Compare aggregate and individual vaccine orders by types of vaccines requested
to determine if the "expected" ratio of vaccines appear. (example 5 DTP, 4 OPV,
3 Hep B, 3 Hib, and 2 MMR ). Significant deviations from the expected ratio will
serve as one means to select sites for office reviews.
Evaluation
The overall success of the NY VFC Program will be measured in a number of ways. We
plan to continue to encourage recruitment of providers particularly those providing
services to large numbers of eligible children; we will continue to assess immunization
levels of two year olds both OD a statewide basis as well as for selected subgroups of
children; and we will monitor whether or not the NY VFC decreases the patient referral
of children from their primary care provider to the local public health clinic as reported by
physicians in a 1993 survey. The following are specific examples of plans to evaluate the
program.
Compare vaccine usage data of local health units from equivalent
periods from prior to VFC and after implementation to determine if
the program has resulted in decreased referrals to public clinics.
Review Medicaid immunization claims by provider to determine
enrollment in NY VFC.
Continue statewide retrospective immunization survey levels of
two year olds.
Review immunization status of patients in VFC provider offices
through the peer review project.
5
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NEW YORK STATE IMMUNIZATION INITIATIVES
1985-1994
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New York State Immunization Initiatives, 1989-1994
The period 1989 to the present has been & time of intense activity
for the New York State Department of Health (NYSDOH) Immunization
Program. The highlights have been efforts to fight the measles epidemic
and to improve immunization levels in preschool age children through
reduction of barriers to immunization, taking advantage of every
opportunity for immunization, outreach to high-risk communities, and
development of & vaccine ordering and distribution system for all health
care providers. As examples of the degree of activity, doses of vaccine
administered through the program have increased over 400 percent from
250,000 doses (1987) to 1,250,000 doses projected in 1994 and vaccine
expenditures by the program have increased from approximately $1.5
million in 1986 to over $18 million projected in 1994.
The period has seen five major additions to the Public Health Law
(PHL) affecting immunizations (mandatory perinatal hepatitis B
screening, college inmunization requirement, Haemophilus influenzae
type b (Hib) day-care requirement, hepatitis B school requirement and
insurance-mandated coverage for immunization). five major amendments
to state regulations (those related to PHL changes plus two-dose mearles
requirements for kindergarten and health care workers) and three
statements of departmental policy in the form of Health Series Memoranda
affecting hospitals and other regulated facilities. Valid
contraindications to immunization, outbreak control guidelines and
required screening and provision of immunizations in health care
facilities.
A timeline of highlights of immunization activities over the past
four years follows:
1. February - June, 1989. Widespread measles outbreaks affecting 12
colleges and nine secondary schools with 91 cases and over 50,000
doses of measles-mumps-rubella (MMR) used in outbreak control.
Total outbreak control costs exceed $1 million.
2. April, 1989. NYSDOE recommends routine two-dose measles
immunization in advance of national advisory groups.
3. June. 1989. PHL 2165 mandates that all post-secondary students in
the state provide proof of immunity to measles, mumps and rubella
in order to attend college.
4. May, 1990. PHL 2500-e mandates screening of all pregnant women for
hepatitis B and treatment of all exposed newborn infants.
5. June, 1990. Measles epidemic begins in New York city (NYC) and
surrounding counties.
6. July, 1990. Amendment to PHL 2164 mandates Hib immunization for
all children less than age five years attending child day care,
nursery school or pre-kindergarten programs.
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'95
1.
7. September - November, 1990. WIC immunization initiative in NYC in
response to the measles epidemic. Ninety-five thousand four
hundred fifteen children in over 100 WIC clinics had measles
immunization status screened, 8,394 (8.8 percent) needed measles
immunization and were known vaccinated as a result of WIC efforts
(3,132 - 37 percent) or referred for immunization.
8. September - November, 1990. Hospital immunization initiative in
New York City, Over 40,000 doses of MMR vaccine were distributed
to 42 hospitals for use in nontraditional settings such as emergency
departments in accordance with Public Health Law 2805-h requiring
hospitals to screen and make available impunizations to all
patients under their care less than 18 years old. Vaccine shortages
were identitied in SCHOOL facilities as a barrier to immunization.
9. January, 1991. Statewide policy adopted to screen immunization
status in all children attending WIC and vaccinate or refer those
needing immunizations. WIC medical referral form updated to
include dates of receipt of all vaccines.
10. April - November, 1991. Study of strategies to achieve immunization
through WIC participation, funded by the Centers for Disease
Control and Prevention (CDC) Infant Immunization Initiative grant.
Attempted to give MMR to eligible children at six NYC WIC sites by
escart to nearby pedistric clinic (two sites), triage to monthly
WIC check pick-up until Droof of MMR provided (two sites) or
referral for immunization without other incentive (two sites). Six
thousand children enrolled, 13 percent were eligible for measles
immunization, and immunization was achieved in 79 percent (escort).
79 percent (check triage) and 35 percent (referral) by the end of
the study period.
11. May. 1991. NYSDOH and NYCDOH successfully request an additional
$1 million from CDC to address vaccine shortages in the NYC Health
and Hospitals corporation facilities.
12. June, 1991. NYSDOH sponsors a one-day conference in NYC for
hospital directors of pediatrics to discuss removing barriers to
immunization within the health care system and encouraging
provision of immunizations in nontraditional settings like
emergency departments in accordance with PHL 2805-h. Notables
attend such as Dr. Saul Krugman, professor emeritus at New York
University and Dr. Walter Crenstein, director of immunization at
CDC.
13. June, 1991. Informal telephone survey conducted of pediatric
directors by DOH professional staff to elucidate barriers to
immunization activities in hospitals. Salient responses include:
high cost of vaccines in private sector and lack of specific
reimbursement for vaccines in clinics and emergency departments,
lack of primary care slots resulting in long waits for appointments,
and reluctance to provide immunizations outside the primary care
setting (e.g., emergency departments).
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14. June, 1991. Section 405.3 of state regulations amended to require
all workers in regulated health care facilities to provide proof
of immunity to measles including two doses of measles vaccine. This
was in response to widespread nosocomial measles outbreaks
involving hospital staff: In 1990, 19 hospitals reported a total
of 74 nosocomial measles cases. 26 involving staff. Four patients
died who acquired measles in the hospital. Fifty-two hospitals were
required by the State to adopt nosocomial outbreak control measures
because of measles exposure. Over 22 hospital worker cases reported
in 1991 including job titles ranging from pediatric neurosurgeon
to housekeeper.
15. August - October, 1991. NYSDOH and New York State Department of
Social Services (NYSDES) conduct an immunization campaign in NYC
using community-based organizations (CBOs) to outreach to
high-risk, hard-to-reach populations such as minorities and illegal
immigrants. In all, 32 CBOs participated and 77 clinics were held
at various neighborhood sites, four Income Maintonance Centers and
three NYS Housing Authority locations. Five thousand six hundred
and five persons were immunized, 1,101 (18 percent) in the target
preschool age groups (under five years old).
16. Docember, 1991. NYSDOH hosts a statewide Immunization Retreat
involving representatives of local health departments. State
agencies including the Departments of Social Services and
Insurance, hospital and professional organizations, physician
groups including PPAC providers, the pharmaceutical industry and
CDC. The agenda involves universal provision of vaccine by the
public sector, but discussion quickly focuses on the need for a
written, comprehensive state immunization plan. The key components
of the plan are discussed.
17. March, 1392. Health Series Memorandum establishing measles
outbreak control policies in health care facilities is published.
28. April. 1992. Health Series Memorandum concerning state policy on
valid and invalid contraindication to vaccination is published.
19. January, 1992. State Immunization Plan (later termed Immunization
Action Plan) is developed and over 20 individuals or organizations
representing health care providers, State/local adjunct health
agencies, voluntary associations, child health advocates are
enlisted to become coalition members to improve immunization levels
of New York State's 0-2 year children.
20. December. 1992. NYSDON hosts a National WIC/Immunization
Conference in NYC attended by WIC and Immunization staff from each
state and U.S. territory. Mrs. Cuomo was the Keynote Speaker.
21. April, 1992. One million two hundred fifty thousand dollars of NYS
Public Health Campaign (PHC) funds are directed to immunization
initiatives. Two hundred fifty thousand dollars of State funds are
matched with Federal funds to create a total of $400,000 to support
11 community-based organization in NYC's highest risk neighborhood
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to identify underimmunized children and to link them to primary care
services. Seven local health units receive PHC funds to expand
their clinic service hours, dates and locations to better serve
underimunized children.
22. February, 1993. Health Series Memorandum detailing requirements
of Public Health Law 2305-h to screen and immunize. as appropriate,
each child under 18 years of age who presents to a health care
facility.
23. April, 1993. A random survey of 1,137 licensed pediatricians and
family-practice physicians in New York were surveyed about
vaccination practices. The responses from this survey provided
information regarding adherence to the Standards for Pediatric
Imminization Practices, physician attitudes about DON Insumnization
initiatives such as vaccine availability and the development of 2
statewide inmunization registry.
24. June - October, 1993. NYSDOH and DSS conduct a pilot study designed
to access children under six years of age who receive AFDC benefits
and review their immunization status. Three models are piloted in
three locations in NYC. The study revealed that the children are
both poorly immunized and receptive to the design of the project.
The immunization levels of the children less than two years of age
ranged between 20-30 percent and over 80 percent of the families
brought the immunization records to the AFDC recertification site
as requested. As a result, additional State-funded projects are
underway in AFDC.sites around NYS (see NBA below).
25. September. 1993 - The Immunization Program developed a PSA to
encourage immunization of children by the age of two which features
the entertäiner Shari Lewis and her puppet Lamb Chop. This PSA is
colorful and antertaining and portrays Shari Lewis and Lemb Chop
in a birthday party celebration setting with balloons, streamers
and a birthday cake. A humorous dialogue takes place between the
two which informs parents of the need to complete a child's
immunization series by their second birthday. When this PSA was
distributed to TV stations statewide, the Growing Up Healthy
Hotline experienced an increase in calls requesting information on
immunizations.
26. 1993. Historic low point for measles incidence in NYS and nation.
27. 1993. Passage of Child Health Insurance Reform Bill mandating that
regulated incurance companies in NYS cover routine pediatric
primary care including immunizations (effective April 1, 1994).
28. 1994. The NYS DOH Immunization Program established contracts with
the ninetean federally funded community health centers in NYS
(exclusive of NYC). Each CHC was asked to perform two specific
tasks: the first is to perform an assessment OF the immunization
status of children two years of age served at their centers: the
second is to identify barriers that may exist in their practices
that may be contributing to underimmunization The goal of the
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Program is to ensure that each of these CHC's institutionalize the
process of assessing the immunization status of children two years
of age and to identify and eliminate barriers that exist preventing
children from being fully immunized.
29. April. 1994. Nineteen Neighborhood Based Alliances (NBA) receive
State PHC funding to hire, train, and place outreach workers at
local DSS AFDC sites to screen immunization levels and ensure lead
poisoning tests are conducted for children less than six years of
age. The outreach workers are responsible for referring and
following up on children who are behind in their immunizations or
who have not been tested for lead poisoning.
30. June, 1994. Immunisation legislation passes which includes
hopatitis B immunization requirement for school attendance (first
State in the nations to do so), broadens the definition of who 16
eligible to consent for the immunization of a child to include adult
family members other than the parent, and allows pilot testing to
determine the feasibility of a statewide immunization registry.
31. October, 1994. Implementation of the New York Vaccines for Children
Program (NY VFC). A Federal vaccine entitlement program for
Medicaid and underinsured children is implemented at the State
level and expanded with State and City funds to cover underinsured
children and all patients seen at local health departments. An
estimated 5,000 private physicians could benefit from the program
by receiving vaccines at no charge to provide to their eligible
patients. Parents who cannot afford the high cost of immunization
will not have to be referred from providers to their local health
unit for one aspect of their child's primary health care needs.
32. October 1994 - The Immunization Program sponsored a statewide
conference entitled "Immunization in the Era of Health Care Reform"
which occurred at the Mehonk Mountain House, New Paltz, New York.
This one and one-half day conference was co-sponsored by the Medical
Society of the State of New York, the New York State Academy of
Family Physicians, the American Academy of Pediatrics and the NEW
York State Association of County Health Officials. This program
was designed to bring together physicians from the private sector
to discuss the challenges of modern immunization practices in the
delivery of primary care. Physicians attending this conference
gained an in-depth understanding of the regulatory and clinical
strategies designed to increase the immunization status of children
by the age of two.
33. October 1994 - Since 1993, local health units have received funding
for local Immunization Action Plans (IAP). To date. 70 new clinic
sites have been added operating an additional 10,000 hours
including 2,000 evening and 500 weekend hours. More than 1,000
outreach activities and 800 educational events have been conducted.
34. December, 1994 - The Immunization Program developed an educational
campaign entitled "Kindergarten Registration* to assist in meeting
the national goal of ensuring that more than 90% of New York's
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IL
two-year old children are adequately immunised by the year 2000.
The objective of this educational campaign is to increase parent's
awareness of the importance of age appropriate immunizations during
kindergarten registration. The focus of this campaign is on the
immunization status of younger siblings. The material to be handed
out and discussed by the school nurse includes a parent flyer,
story/coloring book and a stick-on-badge. The campaign was piloted
throughout New York State during 1994 and is scheduled for
implementation during the 1995-96 school year.
35. Spring, 1995. Three sites were selected for pilot school based
adolescent Hepatitis B initiatives. Rural, suburban and urban
based schools were selected by three county health departments to
implement an educational and Immunization Hepatitis B pilot.
School based clinics and referrals to healthcare providers will be
measured to determine the best means to ensure adequate
immunization coverage for adolescents. The pilots will take place
in the fall of 1995.
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PHYSICIAN VACCINATION REPERRAL PRACTICES
AND VACCINES FOR CHILDREN
NEW YORK, 1994
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4
MMWR
January 13. 1995
Health Objectives for the Nation
Physician Vaccination Referral Practices
and Vaccines for Children - New York, 1994
Although vaccinations are among the most effective preventive public health
measures available. many children are not appropriately vaccinated on time (1). One
identified barrier to timely vaccination is referral by primary-care physicians of chil-
dren to other medical settings for vaccination (2). This report summarizes a survey by
the New York State Department of Health of vaccination referral practices among New
York physicians and describes the implementation in New York of Vaccines for Chil-
dren (VFC). a national program making federally purchased vaccines available at no
cost to health-care providers for administration to eligible children (3).
During April 1993, & rendom sample of 1137 licensed pediatricians and family prac-
tice physiciens notal ne5392) in New York were surveyed by mail about vaccination
practices. Of (68%) responses, 602 (67%) were from actively practicing primary-
care physicians. or these, 250 (50%) referred all or some of their patients elsewhere
for veccinations. Of referring physicians, 225 (91%) referred patients to = local health
department clinic: 108-(64%) fied increased the number of patient referrats during
1983-1993. while seven (3%) had decreased referrals. in addition, 63 (20%) reported
the number of well child visits had decreased during 1963-1993, while five (2%) re-
ported increases during that time. Reasons for referral were provided by 246 of the
250 referring physicians (Table 1) and rated as "very important", "somewhat impor-
tant", or not important". Financial hardship was "very Important" reason for
217 (86%) of those surveyed; the lack of vaccination coverage by private insurance
was "very important" for 132 (54%). Physicians also were asked whether the govern-
ment should underwrite the cost of mandatory vaccinations. Overall, 409 (89%)
respondents indicated that some or all of the costs of childhood vaccination should be
underwritten.
Since October %. 1994, free vaccine has been available at all participating providers
in New York through VFC. Categories of federally engible children include those aged
<19 years on Medicaid, uninsured, underinsured who visited federally qualified health
centers, and American Indian/Alaskan Native children. New York also extended eligi-
bility to include underinsured children in any medical setting and any nonfederally
eligible child served are local health department.
Medical-cere providers were recruited for VFC through articles published in profes-
sional organization newsletters and by mailing of registration packets to licensed
pediatriciens, family physicians, esteopathic physicians, and medical facilities. As of
December 27, 1994, 5 total of 1378 physician practices in New York (including 1972
individual physicians and362 he alth-care facilities) were participating in VFC.
To determine the extent of enrollment by Medicaid providers, time list of VFC -
rollees was compared to # list of providers who billed Medicald for childhood vaccines
during federal fiscal year 1993. Of 2169 physicians who billed Medicaid for childhood
vaccines in 1993. 12:3 (56%) had enrolled. Among the 156 physicians submitting a
minimum of 1000 claims for Individual veccines, 143 (86%) had enrolled. while
653 (68%) of 950 physicians not yet enrolled had submitted fewer than 50 claims.
MAY-04-1995
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94561715 P.22
VeL 44 / No. 1
MMWR
$
Vaccines for Children - Continued
in September 1994, the New York State Department of Health conducted a tale.
phone survey of bealth-care providers who had returned registration forms and
declined perticipation in the program to determine reasons for nonparticipation and to
guide future recruitment efforts. Of the 41 physicians who had declined, 29 (71%) were
contacted. Of these. five (17%) were retired. five (17%) did not accept patients aged
<19 years. six (21%) ware subspecialists or in academic medicine and did not provide
vaccinations, (2%) indicated that most of their patients would not be eligible, and
one (2%) had multiple reasons for not registering; six (21%) with patients who could
benefit from VFC agreed to register as 8 result of the phone cell.
From September 15, 1994, (the first date vaccines could be ordered) through De-
cember 27, 1984. B minimum of 2,496.000 doses of vaccine had been ordered and
more then 2,456,000 does were shipped to VFC participants. The average time be-
tween placement of orders and receipt of vaccine by providers was 1 week.
Reported by: HG Cloirella, MD. GA Bunn, DR Lynch SC Meldrum MS, GS Birkheed, MD, New
York State Dept of Health: $ Freidman MO. N Jenkuaky, MPH. D Mores. MO. State Enidemicio-
New York City Dept of Health: EE Schulle. MD, Alberty Medical Center, Albeny, New York
National Immunization Program, CDC
Editorial Note: in the United States. coverage rates for vsecinating preschool-aged
children against vaccine preventable diseases are among the lowest in the world (ref-
erence ). in New York, only 53% of 2-year-olds during 1989 were appropriately
vaccinated with the recommended vaccines (4). important barriers to timely vaccina-
tion include the high costs of vaccines and the referral of children from the private
sector to the public sector, which delays vaccination. This report demonstrates that
vaccination referrals. in part attributable to high vaccine costs. are common among
New York primary-care providers. Implementation of VFC is expected to reduce these
barriers.
TABLE 1. Importance of reasons for vaccination referral by physicians - New York,
1993
Somewhet
Very important
important
Not important
Reason
No.
(%)
No.
(%)
No.
(%)
Financial herdship
for patient
217
(88)
14
1 6)
15
( 6)
Private insurance.net
covering veccinations
132
(54)
56
(23)
96
(24)
Free veccine to physicians
discontinued by
health department'
110
(45)
34
(14)
102
(41)
High vaccine purchase price
for physician
z
(38)
56
(23)
26
($C)
Insufficient Medicaid
reimbursement
74
(20)
d
(17)
128
(52)
Vaucine svallability
36
(15)
42
(17)
168
(08)
Veccine-refated Web
24
(10)
31
(13)
191
(75)
N-248 or 250 physicians who reported referring patients eisewhere for vaccinations.
As cLApfil 1994, New York State-reguisted major medical health insurance policies, exclu-
sive to self-insured entities. were required to cover all childhood vaccinations.
New York State Department of Health discontinued distribution of free vegoine TO any physician
through county health departments in 1960.
Source: New York State Department of Health
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6
MMWR
Jenuary 13. 1995
Vaccines for Children - Continued
The actual number of VFC participants in New York probably is undersatimated
because many physicians work in facilities or in group practices where only the physi-
clan-in-chief is registered in the program. In addition. the impact of the program on
vaccination coverage and overall occurrence of vaccine-preventable diseases cannot
be determined yes, However, VFC has sllowed New York to Increase provision of VBC-
cine to more children. and in states where vaccines have been made available for all
children, vaccination of preschoolers are approximately 10% higher than the na-
tional average (AG Hollmann, University of Miami, unpublished data. 1993).
The Childhood Immunization Initiative has designated vaccination of preschool-
aged children a national priority and has established a year 2000 gost of vaccinating at
least 90% of children by age 2 years with the recommended number of doses of diph-
therie and tetanus toxoids and pertussis. polio, Hasmophilus influenzae type b.
hepatitis 8. measles, mumps, and rubella vaccine. VFC and elimination of barriers to
vaccination are integral parts of this initiative and will assist physicians and other
health-care providers in reaching this goal.
References
1. NCHS. Health, United States. 1993. Hyattsville. Maryland: us Department of Health and Human
Services, Public Health Service. CDC, 1994; DHMS publication. no. (PHS)94-1232.
2. Sordley WC, Freed GL Garrett JM, Byrd CA. Meriwether R. Factors responsible for immunt.
ration referrals to health departments in North Carolina. Pediatrica 1994;94:376-80.
3. CDC. Vaccines for Children program. 1994. MMWR 1994:43:705-9.
4. Hamburg BG, Dowling FP, Kramer 31. Randles RH. Redeward, LE. Immunization of pre-school
children. New York New York State Public Health Council, Ad Hoc Immunization Committee.
March 1993.
Current Trends
Proportionate Mortality from Pulmonary Tuberculosis.
Associated With Occupations - 28 States, 1979-1990
The rick for occupational exposure to tuberculosis (TB) is increased among health-
care and other workers exposed to persons with active TB, workers exposed to sillica
or other agents that increase susceptibility to TB, and workers in occupations associ-
sted with low socioeconomic status (SES). Accurate estimates of and surveillance for
occupationally acquired TB are limited because most reports of Incident TB cases lack
occupational data. Atthough occupation is routinely recorded on death certificates.
this information is not routinely coded and entered into vital statistics date files. To
identify occupations resociated with increased risk for TB monality, CDC's National
institute for Occupationsl Safety and Health (NIOSH) used date from the National Oc-
cupational Mortality Surveillance (NOMS) database* to conduct s proportionate
Through I collaborative project with NIDSH. the National Cancer tratitute, and COCY National
Center for Health Statistics. the following 28 states have contributed occupation-coded death
certificate data-to B NOME for one of more years between 1979 and 1990: Alaska, California,
Colorado, Georgia, Idaho, Indians, Kenses, Kentucky, Maine, Missouri, Nebroska. Neveda, New
Hampshire, New Jersey. New Mexico. New York, North Carolina, Ohio, Oklahoma, Pennsylve-
nis, Rhode Island, South Carolina, Tennessee, Utah, Vermont, Washington, West Virginia, and
Wisconsin.
TO:
Hillary Rodham Clinton
FROM:
Jennifer Klein
r.k.
DATE:
5/3/95
RE:
Immunization Hearing
A brief update on my progress on the immunization hearing that will be held
tomorrow before the Senate Finance Committee:
1.
Testimony. As I wrote last night, the witnesses are: Dr. David Satcher from the
CDC, a representative from GAO, representatives from the New York State and
Mississippi Departments of Health, Irwin and Dr. David Wood (a pediatrician from
Cedars-Sinai Medical Center).
Here are the highlights of the testimony:
Satcher's testimony provides a strong defense of the program as well as solid
analysis of the problems he was asked to address. He will also emphasize
that VFC is only one part of the Childhood Immunization Initiative (which
also includes investments in infrastructure and efforts to raise awareness
about the importance of age-appropriate immunization).
Irwin's testimony is slightly better than it looked last night, but will still be
very damaging. The other physician's written testimony discusses
immunization rates and barriers to immunization and does not address
problems in the VFC program specifically.
The State Health Officer from Mississippi will testify that cost and
availability of vaccine are not problems in Mississippi. He will talk about the
success they have had immunizing children at public clinics. The
representative from New York will testify that, in New York, studies have
found that cost is a problem and that the VFC program has substantially
improved New York's ability to immunize children.
2.
Members. In addition to the supportive Democrats on the Committee who will be
at the hearing (Rockefeller, Graham, Pryor (who is trying to come), Moynihan and
Moseley-Braun), we expect that Senator Breaux will be very helpful. As of this
evening, Mack McLarty was supposed to call Breaux to thank him for his support.
3.
Groups and Governors Support. We have letters of support for VFC that will be
submitted for the record from: the Association of State and Territorial Health
Officers, SmithKline, the American Academy of Pediatrics, the Children's Defense
Fund, the March of Dimes and the American Public Welfare Association. These
groups have been very active on the hill in preparation for the hearing.
As you know, we also have letters of support from Governors Engler, Dean,
Sundquist and Carnahan.
We will continue to work with the groups and the governors. Unfortunately, we
were unable to get support on the record from the Medicaid directors or the National
Governors Association.
Senator Rockefeller will submit a letter from Sara Rosenbaum clarifying the findings
of her recent study of the 12 universal purchase states. The study found that while
barriers to immunization still exist in those states, the states have had tremendous
success in increasing immunization rates because they provide free vaccine. Irwin
uses the study incorrectly in his testimony by concluding that the study shows that:
"VFC, in its current form, does not confront the factors responsible for severe
underimmunization in the millions of children who have no regular place for health
care. These are the children who really need assistance in getting and sustaining up-
to-date immunizations."
4.
Press. Finally, I have our press office and the HHS press office ready to field any
calls.
Assuring that the Budgetary and Health Care Challenges that Confront
the Nation are Evaluated Fairly and Equitably
WHEREAS the Congress is beginning a historical debate about changes in the Medicare and
Medicaid programs at the same time the delegates of the White House Conference on Aging
are meeting to develop aging and health policy recommendations for the Nation;
WHEREAS the health care cost and coverage shortcomings of the Nation continue to go
unaddressed;
WHEREAS the need for health reform, deficit reduction and assuring the solvency of the
Medicare Trust Fund are inextricably intertwined;
WHEREAS Democratic and Republican Members of Congress joined together before the
Conference to express their support for the Medicare program and the need to strengthen it;
WHEREAS the President of the United States addressed the delegates of the White House
Conference on Aging to further illustrate his commitment to and support for the Medicare and
Medicaid programs, as well as to challenge the delegates to come together on a multi-
generational, bipartisan basis to address the real problems facing this Nation.
THEREFORE, BE IT RESOLVED by the White House Conference on Aging that we
should respond to our Government's challenge to help develop sound health and budget policy
by recommending that any major proposal affecting the Medicare and Medicaid programs
should only be considered in the context of broad-based health reform and should adhere to
the following principles:
Proposals should above all not take our system backwards by reducing coverage for health
care and long-term care, and should be designed to expand coverage and increase long-term
care options;
Older Americans should be provided more choices for alternative health plans, but no
proposal should have the effect of financially coercing beneficiaries into plans that do not
guarantee access to their own doctors.
Quality must not be undermined by proposals to cut the Medicare and Medicaid programs;
Proposals should not produce cost increases to beneficiaries that make health care
unaffordable;
Arbitrary deficit reduction targets should not be the driving force behind reform, but rather
deficit reduction should be a logical outgrowth of sound health policy reforms; and
Savings from proposals that cut the Medicare and Medicaid programs must not be used to pay
for tax cuts for our most well off citizens.
Assuring that the Budgetary and Health Care Challenges that Confront
the Nation are Evaluated Fairly and Equitably
WHEREAS the Congress is beginning a historical debate about changes in the Medicare and
Medicaid programs at the same time the delegates of the White House Conference on Aging
are meeting to develop aging and health policy recommendations for the Nation;
WHEREAS the health care cost and coverage shortcomings of the Nation continue to go
unaddressed;
WHEREAS the need for health reform, deficit reduction and assuring the solvency of the
Medicare Trust Fund are inextricably intertwined;
WHEREAS Democratic and Republican Members of Congress joined together before the
Conference to express their support for the Medicare program and the need to strengthen it;
WHEREAS the President of the United States addressed the delegates of the White House
Conference on Aging to further illustrate his commitment to and support for the Medicare and
Medicaid programs, as well as to challenge the delegates to come together on a multi-
generational, bipartisan basis to address the real problems facing this Nation.
THEREFORE, BE IT RESOLVED by the White House Conference on Aging that we
should respond to our Government's challenge to help develop sound health and budget policy
by recommending that any major proposal affecting the Medicare and Medicaid programs
should only be considered in the context of broad-based health reform and should adhere to
the following principles:
Proposals should above all not take our system backwards by reducing coverage for health
care and long-term care, and should be designed to expand coverage and increase long-term
care options;
Older Americans should be provided more choices for alternative health plans, but no
proposal should have the effect of financially coercing beneficiaries into plans that do not
guarantee access to their own doctors.
Quality must not be undermined by proposals to cut the Medicare and Medicaid programs;
Proposals should not produce cost increases to beneficiaries that make health care
unaffordable;
Arbitrary deficit reduction targets should not be the driving force behind reform, but rather
deficit reduction should be a logical outgrowth of sound health policy reforms; and
Savings from proposals that cut the Medicare and Medicaid programs must not be used to pay
for tax cuts for our most well off citizens.
Assuring that the Budgetary and Health Care Challenges that Confront
the Nation are Evaluated Fairly and Equitably
WHEREAS the Congress is beginning a historical debate about changes in the Medicare and
Medicaid programs at the same time the delegates of the White House Conference on Aging
are meeting to develop aging and health policy recommendations for the Nation;
WHEREAS the health care cost and coverage shortcomings of the Nation continue to go
unaddressed;
WHEREAS the need for health reform, deficit reduction and assuring the solvency of the
Medicare Trust Fund are inextricably intertwined;
WHEREAS Democratic and Republican Members of Congress joined together before the
Conference to express their support for the Medicare program and the need to strengthen it;
WHEREAS the President of the United States addressed the delegates of the White House
Conference on Aging to further illustrate his commitment to and support for the Medicare and
Medicaid programs, as well as to challenge the delegates to come together on a multi-
generational, bipartisan basis to address the real problems facing this Nation.
THEREFORE, BE IT RESOLVED by the White House Conference on Aging that we
should respond to our Government's challenge to help develop sound health and budget policy
by recommending that any major proposal affecting the Medicare and Medicaid programs
should only be considered in the context of broad-based health reform and should adhere to
the following principles:
Proposals should above all not take our system backwards by reducing coverage for health
care and long-term care, and should be designed to expand coverage and increase long-term
care options;
Older Americans should be provided more choices for alternative health plans, but no
proposal should have the effect of financially coercing beneficiaries into plans that do not
guarantee access to their own doctors.
Quality must not be undermined by proposals to cut the Medicare and Medicaid programs;
Proposals should not produce cost increases to beneficiaries that make health care
unaffordable;
Arbitrary deficit reduction targets should not be the driving force behind reform, but rather
deficit reduction should be a logical outgrowth of sound health policy reforms; and
Savings from proposals that cut the Medicare and Medicaid programs must not be used to pay
for tax cuts for our most well off citizens.
MAY-04-1995 09:45 FROM
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TESTIMONY TO
THE UNITED STATES SENATE COMMITTEE ON FINANCE
CHAIRMAN, HONORABLE BOB PACKWOOD
MAY 4, 1995
IMMUNIZING AMERICA'S MEDICALLY UNDERSERVED CHILDREN:
MEDICAL HOMES AND THE VACCINE FOR CHILDREN PROGRAM
By:
Irwin Rediener, M.D., F.A.A.P.
President, The Children's Health Fund
Director, Community Pediatries
and the New York Children's Health Project
Associate Professor of Pedistries
Montefiore Medical Center - Albert Einstein College of Medicine
317 East 64th Street
New York, NY 10021
(212) 535-9707
MAY-04-1995
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Testimony - 5/4/95
Irwin Rediener, M.D.
Senate Finance Committee
Chairman Packwood, members of the committee, I am here to support the Vaccines for Children
Program . but qualify this support based upon certain concerns which must be addressed by
introducing a few important modifications. In general I am suggesting three over-arching goals for
the program:
1. As increasing attention is paid to budget deficits and state versus federal control of public
programs, we need to protect the integrity of the VFC program and health care access for children.
The national agenda for children should not be undermined by multiple state interpretations of what
America's children need. And, VFC should not be endangered by limitations related to possible
fundamental changes in Medicaid structure.
2. We must safeguard against unanticipated consequences of the program as it is currently organized
including the use of precious resources in ways which will not accomplish the goals of VFC in the
most efficient manner possible.
3. Conversely, we need to maximize all available resources -including those provided through VFC -
so that the program targets the children most in need with expenditures targeted to address their
specific barriers to health care and immunizations.
1 am Dr. Irwin Redlener. director of community pediatrics and associate professor of pediatrics at
the Montefiore Medical Center and Albert Einstein College of Medicine in New York. I have had
some 25 years experience in delivering health care and developing programs for disadvantaged
children.
I am also president of the Children's Health Fund, a foundation responsible for establishing
comprehensive pediatric programs for some of the most medically underserved children in the
nation, including the children of homeless, migrant and otherwise severely disadvantaged families
in a wide range of communities.
Children's Health Fund programs operate in New York City; Newark, New Jersey; Dallas, Texas:
rural Mississippi, West Virginia; South Florida; South Central Los Angeles; and Washington, D.C.
These programs have. to date, provided nearly 180,000 medical primary health care encounters to
our designated target populations.
The projects included within our network take children who have had very little organized, quality
health care and provide them with care that is delivered by medical teams who are committed to
quality and continuity.
1
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Testimony - 5/4/95
Trwin Rediener, M.D.
Senate Finance Committee
We ascribe to & notion that the care all children receive should be the kind of care we expect for our
own children. This care should be comprehensive, preventive and organized. Immunizations should
be administered at a place where the rest of their health care is delivered; where follow-up
vaccinations and follow-up for medical problems can be tracked and managed. Where, if needed,
specialty care and hospital care can be coordinated and ensured.
Pediatricians refer to this kind of care as being provided in a "medical home." It is the appropriate
way to do what's right. It's what all children deserve to have.
Children without a medical home may get health care, but it is the worst kind of episodic,
fragmented and expensive medical attention in emergency rooms and drop-in clinics. This kind of
care typically entails little or no follow-up; and, it often does not happen until illness has progressed
too far.
In other words. medically homeless children get the wrong kind of care, in the wrong places, at the
wrong time. It is precisely these children. without regular, dependable access to primary care that
are most likely to be underimmunized.
Conversely, the most important piece of evidence that a child is medically underserved is
underimmunization.
In fact, our programs provide medical care to some of the most medically underserved children in
the United States. For the homeless and extremely indigent children cared for by our flagship
mobile unit program, the New York Children's Health Project, the immunization rates are
devastating:
Some 90% of our pediatric patients, on their first visit to our program are behind in - or
cannot document- their routine immunizations.
This is an extraordinary indictment of the health care system for indigent children and is, to our
knowledge, one of the absolute worst immunization situations in the United States.
Actually, in all of our sites, rural and urban, immunization rates are terrifyingly low and,
importantly, reflective of the sorry state of the child health safety net in the United States. It is my
opinion. that because of factors ranging from lack of health insurance to severe maldistribution of
health professionals, at least 15 million children under the age of 18 years lack appropriate
access to appropriate health care.
2
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Testimony 5/4/95
Irwin Rediener, M.D.
Senate Finance Committee
I need to emphasize this reality: in terms of the most significant causes for the nation's problems
around immunizing our children, the cost of vaccine is not the major factor. Rather, it is lack of
access to a medical home type of health care relationship and the absence of B functioning child
health care safety net in this country which are overwhelmingly responsible for our seeming
inability to consistently protect our children through on-time Immunizations.
The Vaccine for Children Program (VFC) is clearly based on an essential and laudable principle that
all children need to be immunized in an appropriate and timely manner. Our country cannot afford
otherwise. President Clinton and his entire administration are committed to this goal and it needs
to be achieved.
We are, therefore, strong supporters of the VFC but have insisted that it be modified in several
important ways in order to enhance the program's ability to improve the nation's childhood
immunization rates.
Modifications are necessary because of certain problems and issues which have become apparent
as the program unfolds.
I would like to share with you my four principal concerns and specific recommendations to re-shape
VFC:
Concern #1
George Washington University's Center for Health Policy Research recently reported a study of
immunization issues in 12 states where there is universal purchase of vaccine for all children. In
these states, cost associated barriers have been effectively dealt with as factors in
underimmunization.
However, this study verifics our clinical experience in providing immunizations and primary care
to underserved children around the U.S.: VFC, in its current form, does not confront the factors
responsible for severe underimmunization in the millions of children who have no regular
place for health care. These are the children who really need assistance in getting and sustaining
up-to-date immunizations. They need medical homes.
You might look at the issue in this way: underimmunization is a symptom of lack of access to
relevant pediatric health care. The real "trestment" for this problem is guaranteeing access to
3
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Testimony - - 5/4/95
Irwin Rediener, M.D.
Senate Finance Committee
comprehensive health care where immunizations can be given over time and on-schedule.
For the 15 million medically underserved children in the United States the total amount of funds
including the VFC program, Section 317 and other public sector initiatives is insufficient to meet
existing needs. However, right now I am concerned that the relationship between funds spent on
vaccine purchase versus new health provider capacity for disadvantaged children is not in
appropriate balance.
Recommendation:
Congress needs to safeguard the total expenditure for vaccine-related programs so as
not to jeopardize the long-term national agenda for children. But, tax dollars should
not be used to purchase or subsidize vaccines for families with sufficient income
or insurance coverage. These dollars should be re-directed to providing access to
health care for as many medically underserved children as possible. This means
support for infrastructure that is, new capacity to provide comprehensive,
primary health care. Such investments will help public sector provider systems
become more consistent with the medical home model. At the anne time, we
need to ensure that funds to provide vaccines are always sufficient to meet the
needs of the children identified as "st risk."
*********
Concern #2:
The VFC purchase and distribution plan helps families who have 8 regular source of health care
pediatrician, family physician. clinic, etc. but cannot afford or are not covered for vaccines in that
setting. Some are directed to use public health clinics, thereby fragmenting care. Studies have
shown that VFC can help many of these families. But under current VFC guidelines, there is
insufficient monitoring and oversight of under what circumstances and for how long these
families would be eligible for free or subsidized vaccine. In addition, certain VFC provisions
permit states to insppropriately use public funds to provide vaccines for Insured or non-needy
children.
Recommendation
VFC should not offer opportunities for states to use limited public
4
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Testimony 5/4/95
Irwin Rediener, M.D.
Senate Finance Committee
resources to provide free or subsidized vaccines to non-needy or insured
patients. In addition, VFC funds should only provide vaccine to families
until Modicaid or private insurance coverage is obtained.
Concern #3
The VFC program is, of course, a great assistance TO private physicians and their patients since it
eliminates the need to utilize public clinics for vaccinations. Yet, although the private practitioner
benefits from the VFC as a government subsidy, private doctors may still refuse to provide
subsidized vaccine, or any health care, to Medicaid or low-income patients - precisely the
children who are most in need.
Recommendation
Physicians or clinics participating in any aspect of VFC should be
required to accept children covered by Medicaid, children who are
uninsured or those who are otherwise unable to obtain appropriate
health care.
Concern #4
Many insurance companies do not include immunizations in their family coverage. Companies
may surmise that responsibility for the cost of vaccines will simply be assumed by 1 tax-supported
program.
Recommendation
AU insurance policies covering families, whether fee-for-service or
capitated premium based, should be required to include all
recommended vaccines for children.
Members of the Committee:
As I stated earlier children need real medical homes. If every child In this country had 8 medical
5
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Irwin Rediener, M.D.
Senate Finance Committee
home, we would not have the unconscionably low immunization rates we experience in rural and
urban areas around the country.
We need VFC. But it must be modified so that it can really take on and solve one of the most
important challenges of our time.
Finally, it is my hope and that of virtually every health professional and provider organization - that
we can find a way to make sure that every child in the United States has access to appropriate and
essential health care.
At the end of the day, It is health care, not vaccines, that should be guaranteed for children by
government.
I know that the President and the Administration are deeply committed to VFC and access to health
care for the nation's children.
Our job now is to make the adjustments in an important program. that will permit it to function with
maximal impact and in the spirit intended by its original drafters. In this day and age, where ever
more children are vulnerable, endangered and facing an uncertain future, making VFC as effective
as it can possibly be is the least we should do.
Thank you.
###
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TESTIMONY FOR THE SENATE FINANCE COMMITTEE.
MAY 4, 1995
Thank you Mr. Chairman for the opportunity to address you today on
this important topic. My name is Dr. David Wood. I am a
pediatrician practicing in an inner city clinic in Los Angeles
called Para Las Americas. I am also a Assistant Professor of
Pediatrics at UCLA at a health services researcher at RAND and
Cedars-Sinai Medical Center in Los Angeles. I am the principal
investigator on a CDC funded research project to diagnose the
causes of under immunization in Los Angeles. The research team is
composed of health sociologists, maternal child health experts,
economists and statisticians from UCLA School of Public Health and
Dept. of Sociology and RAND, Santa Monica, CA.
The major points I would like to make today are:
1. There continues to be a significant percentage of children who
are under-immunized in this country, especially in poor, urban
populations. A sustained and coordinated effort is needed by
government and the private health care system to raise
immunization rates and keep them high.
2. According to current research, the interventions most likely
to make significant gains in immunization rates are those focused
on the delivery and financing systems for well child care and
immunizations. The primary goals of the interventions should be
to; 1) increase the access for all children to timely well child
visits for all preschool children; 2) increase financial
incentives and reduce administrative barriers for well child care
and immunizations for both providers and parents; and 3) improve
the quality of well child care and immunization delivery by
utilizing all opportunities to delivery the appropriate
immunizations. Due to the complexity of the child health care
delivery and financing systems, the accomplishment of these goals
may require substantially different approaches for different
health sectors.
A significant under-immunization problem still exists.
While surveys of immunization coverage conducted by the Centers of
Disease Control and Prevention (National Health Interview Survey)
have shown increasing rates of immunization coverage for the
population as a whole, disparities in coverage persist.¹ Poor
children, those from traditionally underserved minority groups,
and those who live in urban areas are significantly less likely to
be immunized than the general population. When these risk factors
converge, as they do in many inner city areas, immunization rates
are much lower than for other parts of the US. According to our
data in Los Angeles, at 3 months only 70% of Latino and 51% of
African Americans had received their first immunizations and by 24
months only 42% of Latino children and 25% of African American
children were fully immunized.
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However, these demographic indicators identify not only people-
groups but also the health delivery systems that serve them.
Research clearly demonstrates that the problem lies in these
health delivery and financing systems. While we do know that
variation exists in parental knowledge of immunizations and
motivation to seek immunizations, parents of both immunized and
unimmunized children are equally likely to value immunizations,
believe in the seriousness of vaccine preventable disease and
believe in their efficacy. 2,3 The data suggest that children are
immunized not because of their parents' belief or motivation,
instead parents rather passively follow the advice and direction
of their doctors. Again, problems in the child health delivery
and financing system are largely responsible tor the under-
immunization of preschool children in the US.
Moreover, rather than blame parents it is important to search for
new methods to empower families to increase demand for
immunizations with their providers, especially among particularly
high risk populations. Health passports, distributed widely in
Utah and recently instituted in California and case-management
demonstration projects are all important pieces to the puzzle of
more actively involving parents in the delivery of immunizations.
These efforts need to be sustained long-term. and they must be
coordinated with other educational efforts in WIC and other
programs.
Where do we need to intervene?
It is imperative that we make the existing health delivery and
health financing system improve its efficiency at delivering
immunizations to young children. An important first step in this
process is to promote timely entry into the well child and
immunization system. We muet reach the mothers before they give
birth. Several studies have found that timely receipt of the
first set of immunizations is related to receipt of prenatal care,
early education at WIC visits during prenatal care, and receiving
the appointment for the first well child visit.4 Prenatal care
provides a crucial bridge for a smooth and timely entrance to a
series of recommended health maintenance vicite. Increasing the
connectedness between prenatal care and early well child care can
be accomplished by 1) increasing access to prenatal care for poor,
inner city families, 2) expanding access to WIC and other prenatal
care education programs (such as California's Perinatal Case-
management Program (CPSP) and 31 insuring the connection to a
primary provider for the newborn with all appointment before
leaving the hospital.
Making the well child and immunization delivery system
work.
The American Academy of Pediatrics and EPSDT recommend 7-9 well
child visits during the first two years of life, most of which
correspond with the schedule for immunizations. Half of all
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vaccines delivered in the public clinics in Los Angeles and almost
all of the vaccines delivered in private doctors' offices occur
during well child visits. However, in many areas the majority
children receive less than adequate numbers of well child visits
during the first two years of life, as few as two or three.⁵
Moreover, even among those that receive adequate numbers of well
child visits only approximately half receive the recommended
vaccinations. Why isn't the health care system delivering these
important services to our Nations' children?
To answer that question one must examine our complex child health
delivery and financing system in several discreet sectors; 1)
Medicaid fee-for-service, 2) Medicaid capitated systems, 3)
private health insurance fee-for-service, 4) private capitated
systems and 5) and the uninsured and the systems of care they
access. Each of these sectors has a unique set of incentives and
disincentives for the delivery of well child care and
immunizations. I will examine the barriers to well child care and
immunizations and potential interventions to raise immunization
rates within each of these sectors.
Medicaid Fee-for-service.
Medicaid and EPSDT are the primary financing systems for well
child care and immunizations for approximately 25% of America's
children. In our study we found that African American children
with Medicaid insurance were only one-fourth as likely to be fully
immunized by 24 months as African American children with private
insurance. 6 A 1990 American Academy of Pediatrics study of
preventive services use by California Medicaid children found that
only 20%-30% received preventive EPSDT services in the prior year. 7
Children on Medicaid are much less likely to have had a preventive
health examination in the past year than privately insured
children.8
Why is Medicaid so ineffective at promoting timely well child care
and immunizations? The answer is primarily that Medicaid does not
adequately reimburse providers for the services. Under Medicaid
fee-for-services, reimbursement rates for well child care and
immunizations are notoriously low and payments are often delayed.
State reimbursement rates to private providers for a vaccine and
its administration average approximately one-half of the UCR for
these services. Compared to UCR fees, the typical Medicaid
program underpays physicians $40 to $60 per well child visit
(physical examination and immunization administration). Medicaid
payment rates for these services have eroded badly over the past
decade as States have been slow to review and raise payment
schedules. California has not raised the immunization
administration fee in over a decade. 10
As a result of these poor reimbursement rates providers are either
neglecting to provide these services to their Medicaid patients as
compulsively as recommended or they are increasingly referring
patients to the public sector for these services. Under either
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scenario, fewer and tewer children are receiving timely well child
care and immunizations under the current Medicaid fee-for-service
system.
Recommendation. Reimbursement rates for well child care and
immunizations under Medicaid must be increased in order to promote
their timely delivery. A state or federal based bulk vaccine
purchase program is one vehicle to accomplish this. It has the
substantial advantage of being cost-neutral. Under Medicaid fee-
for-service programs, physicians purchase vaccine at the catalogue
price and States reimburse providers for the catalogue price of a
vaccine, approximately double the cost of the bulk purchased
vaccine. 11 The substantial savings accrued under bulk purchase can
be invested in increasing the administrative fees to providers.
This approach was suggested by a California nonpartisan task force
report in 1992. 12
Thus, under a bulk purchase program positive incentives to private
providers include relieving them of carrying the substantial cost
of a vaccine supply, and raising reimbursement rates for vaccine
administration In States that already bulk purchase and
distribute vaccine this approach has been successfully at
increasing providers willingness to administer vaccine and reduce
referrals to the public clinics. 13 Important factors in the
success of a bulk purchase program are that; 1) the distribution
system be efficient, and 2) providers not be overly burdened with
eligibility determinations nor vaccine use reporting. The
California Vaccines for Children has recently instituted a bulk
purchase program with a private pharmaceutical distributor that
appears to be user friendly and makes minimal paperwork demands on
providers.
An alternative approach is to simply raise Medicaid fee-for-
services reimbursement fees to providers for well child visits and
for the administration of immunizations. However, this approach
would entail substantial increases in costs in the Medicaid
program.
Medicaid Managed Care.
We found the lowest immunization rates in the inner city of Los
Angeles among children enrolled in Medicaid managed care. 14 Of
children in HMOs only 33% were UTD. Between 1987 and 1992 states'
total enrollment in Medicaid managed care more than doubled. 15 In
December of this year approximately 2.5 million California
Medicaid recipients will be switched from Medicaid fee-for-service
to Medicaid Managed care. 16 The few studies that have examined
Medicaid managed care indicate that it may or may not increase
access to routine preventive services. 17 In some settings, access
to well child care and immunizations may even deteriorate.
Private managed care premiums are established based on the cost of
providing a determined set of benefits. Medicaid managed care
benefits are set by federal regulation and are generally broader
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than those provided in the private sector. In order to reduce
costs, however, States set Medicaid capitation rates based
capitation rates not on the costs of providing the benefit package
but on a reduced percentage of expenditures in the Medicaid fee-
for-service program. Moreover, to the extent that Medicaid
programs are already among the lowest paying third-party payers,
further discounting rates in managed care can leave providers
without sufficient funds to provide needed care and may
dramatically increase the incentive to under-serve. 18 Routine
preventive services such as well child care and immunizations
comprise a significant proportion of the capitated reimbursement
during the first two years of life (after birth related health
expenses), and they may be easy targets for under-service by
plans.
Health Maintenance Organizations under managed care capitated
contracts traditionally have actively promoted preventive services
as a means to prevent more costly events in the future, such as a
hospitalization for a measles infection. Indeed, Kaiser and other
HMOs serving the middle class have some of the highest
immunization rates in the Nation. However, under Medicaid managed
care the incentive to provide preventive services is largely
eroded by the extreme instability of the enrolled population. It
is estimated that 10% of Medicaid AFDC enrollees loose Medicaid
coverage each year. 19 When they regain coverage after of period of
months, they are likely to join a different health plan, causing
dramatic populations shifte among managed care plan. One managed
care medical director characterized the problem in the following
terms; "If our plan expends significant resources to bring
children that are behind, up-to-date on their immunizations, which
we do, we are doing the work the previous plan should have done,
and we are saving money for the next plan in which the child will
enroll six months from now
Recommendations. The Federal and State governments must
structure the Medicaid managed care programs such that all
children have access to well child care and immunizations
according to the EPSDT guidelines. States should set Medicaid
managed care capitation rates to insure that there are adequate
resources to provide the mandated services at high quality.
States must provide adequate oversight to Medicaid managed care
plans. The Federal Health Care Financing Administration strongly
criticized the State of California for its near complete lack of
oversight of early experiments with Medicaid managed care. 21 Many
abuses of Medicaid managed care resulted, including very low
immunization rates in inner-city Los Angeles.
To increase the effectiveness of States' oversight of Medicaid
managed care plans delivery of preventive services, States should
requiring plans to report encounter based data on EPSDT services,
including immunizations and population based immunization rates
In the fall California passed legislation requiring this kind of
reporting of all Medicaid managed care plans. To put teeth into
the oversight process, States should provide financial incentives
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to plans for raising immunization rates and providing other EPSDT
services according to the guidelines as well as penalize plans
that do not perform well. This program could be financed in part
from the savings accrued from a vaccine bulk purchase program
similar to the Vaccines for Children program.
Private Insurance system.
Approximately 60% of US children are covered by employee based
private insurance. 22 A 1989 by the Health Insurance Association of
America Survey found that only 45% of conventional employment
based insurance plans covered basic childhood immunizations 23
Health maintenance organizations provide much better coverage of
well-child care, with 98% paying for immunizations. 24 Many states,
including California, have passed laws in recent years to require
employer based health plans to cover immunizations. However, up
to 60% of employer self-insured health plans are exempt from state
regulation under the Employer Retirement Income Security Act
(ERISA) of 1974. 25 The combined effect of the lack of coverage in
private insurance and rising vaccine costs and rising
administration costs for providers has placed a significant
economic burden on families. Rather than pay these costs, up to
$500 dollars for the cost of the full set of childhood
immunizations and their administration, 26 many families are opting
to refuse immunizations at the private providers office. More and
more private providers are referring families to the public
clinics for immunizations, overwhelmingly citing cost of the
vaccine to families as the primary reason. 27 This shift from the
private to public sector has placed increase strain on an already
overburdened public sector. Moreover, the added transportation
and time costs will likely discourage many families from obtaining
immunizations in a timely fashion.
Recommendation. The Vaccine for Children program makes
provision for children with health insurance that does not cover
immunizations, however, the program as designed also prevents them
from receiving the immunizations at their private provider's
office. Under the VFC program, children in this category can
receive free vaccine ONLY at Federally Qualified Health Centers
(FQHCs). FQHCs are generally located in poor, inner-city or rural
areas, relatively inaccessible to the large percentage of middle
class families that will fall into this category. Moreover, no
provision in made in the VFC program to increase the capacity of
FQHCs to handle the increase demand for well child care and
immunizations.
A more rational approach would be to amend ERISA to give states
the authority to mandate employer self-insured health plans to
cover child preventive health services. This may not be
politically feasible at this time. However, there are two private
sector trends may reduce the children who have insurance but no
coverage for immunizations. First, various forms of managed care
plans. such as Preferred-Provider-Organizations, are rapidly
replacing classic fee-for-service indemnity plans and a growing
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P.30
percentage of these managed care plans cover child immunizations
and well child care. Secondly, employer purchasing cooperatives
are increasingly demanding outcomes based reporting or health
report cards from health plans. All of these health report cards
include child immunization coverage levels as one indicator of the
quality of care provided within plans. In order to optimize
quality ratings, more and more plans are voluntarily covering
immunizations and well child care for children.
Uninsured children.
Almost 15% of US children lack any form of health insurance. In
our studies, lack of insurance is an important predictor of under
immunization. Uninsured Latino children were only half as likely
to be fully immunized by 24 months as privately insured Latino
children. 28 There are two fairly distinct groups among the
uninsured; the poor and the non-poor (the later is the larger
group). The poor, uninsured are the traditional users of public
clinics, which have become even more overburdened by the
increasing numbers of referrals of privately and publicly insured
children. While in our studies over half of poor, uninsured
children utilized public health clinics for well child care and
immunizations, almost 40% sought care at private providers
offices. This number is certainly higher among non-poor,
uninsured children. Families of non-poor, uninsured children face
similar financial barriers to receipt of immunizations at their
private doctor's office as we describe for insured but uncovered
children. Many will seek free immunizations rather than pay the
high cost of receiving the immunizations in the private sector.
Poor, uninsured families should qualify for EPSDT payment programs
for well child care and immunizations at a private doctors office.
The California EPSDT program covers children in families with
incomes of up to 200% of the poverty line (approximately $28,000
annual salary for a family of 4). However, the California EPSDT
program only reaches 30% of eligible poor children with well child
or immunization services. 29 Few providers accept EPSDT clients due
to low reimbursement rates, late payments, frequent and often
capricious denial of claims and burdensome paperwork requirements.
the billing requirements of EPSDT are also a significant barrier
to physicians. EPSDT in California does not utilize standard CPT
or ICD9 billing codes and therefore is not accessible to most
office computer billing software.
The Vaccines for Children program allows provider to administer
vaccine received at no cost to poor or non-poor, uninsured
children. Providers are allowed to charge up to a $15
administration fee for each vaccine. Subtracting the cost of the
vaccine product, the cost of immunizations for the parent will
decline at least 40%. Some providers may reduce their
administrative fee for uninsured families, further reducing the
families' financial burden. This may allow many non-poor families
to receive immunizations from their private providers.
MAY-04-1995 09:30 FROM
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94561715 P.31
For poor, uninsured populations eligible for EPSDT, the VFC
program or similar bulk purchase program will strengthen the EPSDT
program's financial incentive to providers by relieving them of
the cost of advance purchase of vaccine and by increasing the
vaccine administration fee (in California the fee is projected to
rise from its current rate of $4.52 per vaccine to approximately
$7.50 per vaccine). This may induce many more providers to
participate in the EPSDT program or accept more EPSDT clients.
Recommendations. The VFC program could strengthen its
provisions for uninsured children by reimbursing providers for
both the cost of vaccine and its administration. This would
eliminate the financial barrier to immunizations for uninsured
children. However, since immunizations are generally delivered in
private offices only accompanied by a full physical exam, the cost
of the visit would still be born by the families. The EPSDT
program will be significantly strengthened by the VFC program or a
similar bulk purchase program. In order to induce the maximum
number of providers into the program, EPSDT program should also
dramatically reduce the paper work burden to providers though the
institution of a simple, electronic billing capabilities similar
to Medicaid or other health insurance, utilizing standard CPT and
ICD9 codes.
The last major factor contributing to the low immunizations rates
is an issue of quality, generally unrelated to the structure of
health delivery systems or health financing systems. In many well
child and other health care visits, children fail to receive the
immunizations that are due. This is referred to as a missed
opportunity to vaccinate. Missed opportunities to vaccinate are
responsible for approximately 50% of the delay in immunization
receipt. 30
Children coming into public and private offices for well child
care fail to receive the needed immunization at approximately 40%
well child visits and at the vast majority of illness visits. 31
Studies have shown that even when children receive adequate number
and timing of well child care visits, immunizations may not be
received, resulting in significant delays in the receipt of
immunizations. 32
Why do providers miss so many opportunities to vaccinate? Data
indicate that physicians and nurses do not adequately understand
the immunization schedule. In our chart abstraction study
nurses accurately assessed immunizations needed only 27% of the
time. Secondly, providers have misunderstandings of what
constitutes a contraindication to vaccinate a child, so that they
frequently defer immunizations inappropriately.34
Recommendations. The CDC and the professional societies have
already taken a number of positive steps to address the epidemic
problem of failure to give the appropriate immunizations at a
health visit. The AAP and the ACIP recently jointly published a
simplified immunization schedule, making it easier for providers
MAY-04-1995 09:31
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94561715 P.32
to understand the schedule and assess a child's need for
immunizations. 35 In addition, the CDC has published and
disseminated the Pediatric Standards for Immunization Practices,
which explicitly refute many commonly held misinterpretation: of
contraindications, and clearly delineate the true
contraindications for each vaccine. These true contraindicat:ons
are in fact, rare.36
The Standards need to be disseminated more widely and more clearly
adhered to by providers in both the public and private clinical
setting. In addition, education efforts for providers should be
intensified to raise the knowledge level of providers on
immunization practice. However, it is unlikely that simply I aking
information available to providers will change their beliefs or
their behavior. 37 Studies indicate that the dissemination of
practice guidelines or clinical recommendations may not chang e
provider beliefs or cause behavior to conform to the new
recommendations. 38 Incorporating provider education on guide ines
into an ongoing, active process of quality improvement would
greatly increase the chances of successful adoption of clinical
guidelines. 39 This includes, but is not limited to, active
participation by providers in the construction and measuremer = of
outcomes (e.g., immunization levels and rates of missed
opportunities to vaccinate) in their own practices, and the
institution of an evaluation and feedback process to measure the
impact of policy changes. The American Academy of Pediatrics has
produced simple but effective materials for providers to appl
Quality Improvement principles to their delivery of childhooc
immunizations. 40 The CDC, through local health departments and
Immunization Action Plans, should provide the technical leade rship
to institute the quality improvement processes in the public and
private provider organizations. In order to do this in a cost
effective manner our nation must invest in an automated data
system that tracks immunizations and other important quality
indicators on all children.
Conclusions
Immunizations rates remain dangerously low in the many areas in
the United States, providing a potential reservoir of suscept ible
for disease epidemics. Our child health delivery and health
financing systems are complex and interventions must be tailored
to the specific delivery/financing system. It is imperative to
assure that adequate financial incentives are built in to include
physicians to administer immunizations under all public and
private health care delivery and financing systems. In Fee-lor-
service systems adequate first dollar coverage for well child care
and immunizations must be provided at reimbursement levels
adequate to cover provider costs and to induce them to participate
vigorously in the delivery of these essential services. Managed
care plans should be monitored carefully and performance baced
incentives should be built into capitation rates based on the ir
documented well child care and immunization performance standards.
High risk, poor and inner-city populations may continue to b.
MAY-04-1995 09:32 FROM
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94561715 P.33
largely dependent on the public sector and may be more costly to
immunize. Adequate support for basic public health infrastructure
is crucial to the provision of high quality services to these
populations and the prevention of future epidemics.
Thank you, Mr. Chairman for the opportunity to speak to your
committee today.
1Centers for Disease Control and Prevention. Vaccination coverage for 2-year-
old children--United States, 1993. MMWR. 1994:43 (39) : 705-709.
²Miller LA, Hoffman RE, Baron AE, et al. Risk factors for delayed
immunizations against measles, mumps and rubella in Colorado two-year-olds.
Pediatrics. 1994;94:213-219.
3Bates AS, Fitzgerald JF, Dittus RS, et al. Risk Factors for
underimmunization in poor urban infants. JAMA. 1994;272:1105-1110. Orenstein
WA, Bernier RH. Delivering vaccines to young children. prentation at the
ICAAC Meeting, October 5. 1994, Orlando, Florida. Wood D. Halfon N,
Sherbourne C, et al. Increasing Immunizations for African American and Latino
Preschool Children in the Inner City of Los Angeles. Report. Contract Number
200-91-0942 CDC, 1993.
4 Wood DL, Sherbourne CD, Halfon N, et al. Factors Related to Immunization
Status Among Latino and African American Inner-city Preschoolers. Pediatrics.
(in press) Bates AS, Fitzgerald IF Dittus RS. et al. Risk Factors for
underimmunization in peor urban infants. JAMA. 1994;272:1105-1110.
SWood DL, Pereyra M, Halfon N, et al. Vaccination levels in public health
conters: Missed Opportunities and Other Contributing Factors. Am J Public
Health. (in press). Mustin HD, Hold VL, Connell FA. Adequacy of well child
care and immunizations in US infants born in 1988. JAMA. 1994;272:1111-1115.
6Wood DL, Sherbourne CD, Halfon N, et al. Factors Related to Immunization
Status Among Latino and African American Inner-city Preschoolers. Pediatrics.
(in press).
7Immunizing California's children. A report commissioned by Lt. Gov. Lec
McCarthy. Institute for the Study of Social Change, UC Berkeley, 1992.
Halfon N, Hughes D, Brown S, Wood DL, et al. Health Care Reform: What
America's Children Need. A briefing paper for Congress. Prepared and
distributed with assistance from the Carnegie Corporation of New York, the
California Wellness Foundation, Henry J. Kaiser Family Foundatio, August,
1994. Wood D. Hayward R, Freeman H, Covey C. Shapiro M. Access to Medical
Care for Children in the United States. Fediatrics. 1930, (5) 666-673.
Liu J. Rosenbaum S. Medicaid and childhood immunizations: A national study.
Childrens Defense Fund, Washington DC, 1992.
10Dales, Loring. Memo from Loring Dales, Head, California Department of
Health Services Immunization Branch, May 4, 1995.
"Orenstein WA. Bernier RH. Delivering vaccines to young children.
prentation at the ICAAC Meeting, October 6, 1994, Orlando, Florida.
12 Immunizing California's children. A report commissioned by Lt. Gov. Leo
McCarthy. Institute for the Study of Social Change, UC Berkeley, 1992.
13kuch-Ross HS, Connor KG. Immunisation referral practices of Pediatricians
in the United States. Pediatrics. 1994;94:508-513.
14Wood D, Halfon N, Sherbourne C, Grabowsky M. Access to Infant Immunizations
for Poor, Inner City Families: What is the Impact of Managed Care? Journal
Health Care for the Poor and Underserved. 1994; (2) 112-123.
General Accounting Office. Medicaid: States turn to managed care to
improve access and control costs. GAO?HRD-93-46. United States Congress.
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Washington, DC: General Accounting Office; March, 1993.
16california Department of Health Services. Expanding Medicaid managed care
plan; reforming the health system, protecting vulnerable populations.
Sacramento, CA, March 1, 1993.
Freund DA, Lweitt EM. Medicaid managed care for children and pregnant
women: promises and pitfalls. Future Child. 1993:3(2):92-122.
¹⁸Freund D. Rossiter L, Fox P, et al. Evaluation of the Medicaid competition
demonstrations. Health Care Finan Rev. 1989;66:618-639.
19Freund DA, Lweitt EM. Medicaid managed care for children and pregnant
women: promises and pitfalls. Future Child. 1993:3(2):92-122.
20Conversation ugust 25, 1994 with Gene Beed, MD, Corporate Associate Vice
President for Medical Informatics, FHP. Health Care.
21Health Care Financing Administration. Review of California's Administration
of Its managed care program. San Francisco, CA: Department of Health and
Human Services, 1990.
22Liu J. Rosenbaum S. Medicaid and childhood immunizations: A national study.
Childrens Defense Fund, Washington DC, 1992.
23Immunizing California's children. A report commissioned by Lt. Gov. Leo
McCarthy. Institute for the Study of Social Change, UC Berkeley, 1992. p. 10.
24National Vaccine Advisory Committee. "The measles epidemid: The problems,
barriers and recommendations. JAMA. 266 (11) 1547-1552, 1991.
5Freed GL, Katz SL. The Comprehensive Childhood Immunization Act of 1993:
Toward a more rational approach. N Engl J Med. 1993;329:1957-1960.
"Orenstein WA. Bernier RH. Delivering vaccines to young children.
prentation at the ICAAC Meeting, October 6, 1994, Orlando, Florida.
27 Schulte JM, Bown GR, Zetzman MR, et al. Changing immunization referral
patterns among pediatricians and family practice physicians, Dallas County,
Texas, 1988. Pediatrics. 1991;87:204-207. Ruch-Ross HS, O'Connor KG.
Immunization referral practices of Pediatricians in the United States.
Pediatrics. 1994;94:508-513.
28wood DL, Sherbourne CD, Halfon N, et al. Factors Related to Immunization
Status Among Latino and African American Inner-city Preschoolers. Pediatrics.
(in press).
"Immunizing California's children. A report commissioned by Lt. Gov. Leo
McCarthy. Institute for the Study of Social Change, UC Berkeley, 1992. p. 10.
30 Szilagyi PG, Rodewald LE, Humiston SG, et al. Missed Opportunities for
Childhood Vaccinations in office Practices and the Effect on Vaccination
Status. Pediatrics 1993;91(1):1-7.
311) Wood DL, Pereyra M, Halfon N, et al. Vaccination levels in public health
centers: Missed Opportunities and Other Contributing Factors. Am J Public
Health. (in press).
2) Hutchins SS, Escolan J, Markowitz LE, et al. Measles Outbreak Among
Unvaccinated Proschool-Aged Children: Opportunities Missed by Health Care
Providers to Administer Measles Vaccine. Pediatrics 1989;83 (3) 369-374.
31 Lee SH, Ewert DP, Frederick PD, Mascola L. Resurgence of Congenital
Rubella Syndrome in the 1990s: Report on Missed Opportunities and Failed
Prevention Policies Among Women of Childbearing Age. JAMA (19) :2616-
2620.
4) Farizo KM, Stehr-Green PA. Markowitz LE, Patriarca PA. Vaccination Levels
and Missed Opportunities for Measles Vaccination: A Record Audit in a Public
Pediatric Clinic. Pediatrics 1992;89 (4) 589-592.
5) Steinhoff MC, Cole P. Cole A, John TJ, Pereira SM. Evaluation of the
opportunities for and contraindications to immunization in a tropical
paediatric clinic. Bull World Health Org 1985; (5) 915-918.
6) Cutts FT, Zell ER, Soares AC, Diallo S. Obstacles to Achieving
immunization for all 2000: Missed Immunization Opportunities and
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Inappropriately Timed Immunization. J of Tropical Pediatrics 1991;37:153-158.
³Guyer B, Hughart N, Hold E. Ross A, Stanton B, Keane V. et al. Immunization
coverage and its relationship to preventive health care visits among inner-
city children in Baltimore. Pediatrics. 1994;94:53-58. Mustin HD. Hold VL,
Connell FA. Adequacy of well child care and immunizations in US infants born
in 1988. JAMA. 1994/272:1111-1115.
Wood D. Halfon N, Sherbourne C. et al. Increasing Immunizations for African
American and Latino Preschool Children in the Inner City of Los Angeles.
Report. Contract Number 200-91-0942 CDC, 1993.
34 McConnochie KM, Roghmann KJ. Immunization opportunities missed among urban
poor children. Pediatrics. 1992;89:1019-1026. Hughart N. Guyer B, Stanton
B, Strobino D. et ai. no provider practices conform to the new pediatric
immunization standards. Arch Pediatr Adolesc Med 1994;148:930-935.
35Hall CB. The recommended childhood immunization schedule of the United
States. Dediatrics. 1995:95:135-137.
³⁶Ad Hoc Working Group ofr the Development of Standards for Pediatric
Immunization Practices. Standards for pediatrics immunization practices.
JAMA. 1993;269:18917-1821.
Kibbe DC, Kaluzny AD. McLaughlin CP. Integrating guidelines with continuous
quality improvement: Doing the right thing the right way to achieve the right
goals. J Quality Improvement. 1994;20(4) :181-191.
38Kanouse DE, Kallich J. Kahan JP. "Dissemination of practice-relevant
information to health care providers and payers." Paper presented at the
National Agenda Setting Conference in Outcomes and Effectiveness Research, Apr
14-16, 1991.
39 Batalden PB, Stoltz PK. A framework for the continual improvement of health
care. J Quality Improv 1993; (10) 424-446
American Academy of Pediatrics. Ambulatory Care Quality Improvement
Program: 1) Vaccine storage, 2) Immunization medical record keeping.
American Academy of Pediatrics, Elk Grove Village. IL, 1992.
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HUMAN SERVICES USA
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
&
OFFICE OF THE ASSISTANT SECRETARY FOR LEGISLATION
HEALTH
OFFICE OF HEALTH LEGISLATION
HUH Bldg, Room 405H
of
200 Independence Avenue, SW
Order
Washington, D.C. 20201
PHONE:
690-7450
FAX:
690-8425
FROM:
TO:
Junnife Kleen
mumsa
I
Department of Health and Human Services
/
NAME:
3
/
OFFICE:
Bridgett Taylor
Associate Director (Health)
ROOM #:
Office of the Assistant Secretary for Legislation
200 Independence Avenue, S.W.. Room 409-H HHM 202/590-7450 Ofc
PHONE #:
456-2599
Washington, D.C. 20201
202/890-8425 Fax
FAX #:
456-2878
DATE:
5/3/95
PAGES:
(INCLUDING COVER)
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Jennifer --
The outside groups which we have contacted are:
1. The Association of State and Territorial Health Officers.
2. The Academy of Pediatricians
3. The Children's Defense Fund
4. March of Dimes
5. The American Public Welfare Association
6. National Governors Association
7. Smith Klein (Vaccine Manufacturer)
All of these groups except for NGA agreed to do letters for the
record. I will send you copies as they arrive. APWA's and Smith
Klein's might not make it before the hearing, but they will get
them in before the record closes.
The members we expect to be at the hearing tomorrow are:
Senator Moynihan
Senator Breaux
Senator Graham
Senator Pryor (maybe)
Senator Rockefeller
Senator Moseley-Braun
Senator Packwood
Senator Chafee
Senator Simpson
I left a message for Marsha Hobes in Intergovernmental and she
hasn't returned my call. Our people in public affairs will
contact Jake Seaword.
One additional piece of information on American Home Products.
They are apparently floating an alternative to the VFC which
they are saying will provide states with more flexibility. I've
heard is similar to a block grant.
Let me know if you need anything else.
Bridgett
94562878;# 3
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FILE No. 288 05/03 '95 13:03 ID:AMER.ACADEMY PEDS.
1 202 393 6137
PAGE 2
American
Academy of
Pediatrics
601 Thiresonth Street, N.W.
Suke 400 North
News Release
Washington. DC 20005
CONTACT: Marjorie Tharp
FOR RELEASE: May 3, 1995
800/336-5475
202/347-8600
BUDGET PROCESS THREATENS VACCINE PROGRAM
Washington, D.C. -- The American Academy of Pediatrics (AAP) is urging Congress to
maintain federal funding for the Vaccines for Children (VFC) program, which provides free
vaccine to children meeting certain requirements.
"Americans want fiscal responsibility," AAP President George Comerci, M.D., said, "and in
this case, the economic sense comes from investing money in a preventive service now to
avoid higher health care costs later."
The Senate Finance Committee will review the VFC program tomorrow, 9:30 a.m., 215
Dirksen, to determine whether funding should be cut or climinated so that the savings can be
used towards balancing the budget.
The VFC program, just 8 months old, guarantees free vaccine to children ago 18 or younger
who are Medicaid eligible, uninsured or Native American. Underinsured children are eligible
if they receive care at a federally qualified health center.
According to the AAP, the VFC program addresses most of the barriers some parents faced in
delaying their child's immunizations, such as:
offering free immunizations for children in working, middle-class families
whore dependent coverage is either not included or has been dropped;
-more-
94562878:# 4
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1 202 393 6137
PAGE 3
VFC PROGRAM
2-2-2
providing states the option to purchase additional vaccines at a reduced
price to cover underinsured children whose Insurance doesn't include
immunizations;
allowing Medicaid and Native American families to receive immunizations
in a medical home.
assuring that all eligible children will receive the benefits of newly
recommended vaccines for school entry, causing immunity lovels in the
community to strengthen.
"The truth is that medical science has done such a fantastic job of virtually eliminating these
infoctious diseasos," Dr. Comerci said. "People have forgotten what it was like when
diphtheria. pollo and other contagious diseases were common.
"Clearly, vaccine manufacturers have shared in this success story. We must ensure that they
are able to continue their research and development of new and better vaccines.
"But make no doubt about it, we still need the government's financial support for the VFC
program to guarantee that our children, and subsequently the communities they live in, are
free of preventable diseases.
"Immunizing children is a public health issue. Until all children and adolescents have
financial access to comprehensive health care, the VFC program must remain intact."
The VFC program was appropriated $348 million for fiscal year 1995. President Clinton's
Oscal year 1996 budget proposes $365 million.
###
The American Academy of Pediatrics is an organization of 49,000 pediatricians dedicated in
the health, safety and well-being of infants, children. adolescents and young adults.
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5- 2-95 : 8:25AM
COC/NIC-
202-090-8598;# 27 2
rew.
1 202 393 6137
PAGE 2
American
Academy of
Pediatrics
May 1, 1995
David Satcher, M.D.
Director. Centure for Disease Control and Prevention
1600 Clifton Road, NE
Atlanta, GA 30333
Department of Government
Liateon
American Accidency Pediatrice
Dear Dr. Satcher:
The Memer Bunding
601 Thirteen Street, NW
Suite 400 North
The American Academy of Podiatrics, and, more importantly, the families
Washington, DC 20006
202/347-8800
we serve, urge your continued support for the Vaccine for Children
BOO/326-8478
(VTC) Program. Although the program to only in Infancy (8 months)
Fax 202/393-6137
and has had more than in share of growing pains, over 36 states have a
complete program, with the remaining in various stages of development.
Unit all children and adolescents have financial access to comprehensive
health care, the VFC program provides an important remedy for obstacles to
our nation's immunization initiative in 4 important areas:
1) is provides immunizations for the Increasing number of children in
working, middle-class families where dependent coverage is eicher not
covered or dropped:
2) is assures that all eligible children will receive the benefits of
President
newly recommended vaccines for school entry. thus strengthening
George D. Comera. MO
immunity Levels of the community:
Vice President
Maurica C. Keenen, MD
3) it gives wates the option to purchase additional vaccines to cover
Past President
the so-called underlasured children who have typical insurance
Barry A. Laws, MD
policies which don't include immunisations; and
Executive Director
4) is allows Medicaid and native American families to receive
Jae M. Sanders, Jr. MD
inmunizations In I medical home.
Banco of Directors
The VFC Program is an integral part of this nation's goal of protecting its
Glibert L. Fuel MO
Keans, New Hampshire
youngest citizens from the cavages of vaccine-preventable diseases. It must
Lauis 2. Cooper: MD
be viewed within the context of all other public and private health initiacives,
New Yerk, New York
each contributing an important element. A premature hair to the VFC
Susan MD
Program In the absence of universal ACCOSE to health care including
Narbonh, Pennsylvania
Joseph R. Zarga MD
immunizations, would leave many children in Limbo and vulnerable to
Ristimend, Virginia
disease.
Robert E. Hannamann. MD
La/ayette, Indiana
The VFC Program is deserving of your support.
Thomas P. Tomiges. MD
Hastings. Nebrauha
Carden Johnston, NP
Sincerely yours,
Birmingham, Nabama
Dened a. Cook MD
Years D Comerce IMD
Gradley. Colorado
George D. Comerci, M.D.
Leonand A. Kumik, MD
President
San Clage, Certernia
The Anerican Acadumy of Padiatrics is asmitted to the atteinment of optimal physical,
mantal, MPO socied health for all inlants. chadren, adolescents, and young adults,
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MAY 03 '95 12:54 FR MARCH OF DIMES DC
202 296 2964 TO 6908168
P.02
Marchaft
March of Dimes
Date:
Birth Defects Foundation
National Government Affairs Office
1901 L firest N.W., Suite 200
Washington DC 20038
Telephone 202 650 1800
FAX 202 298 2084
May 3, 1995
The Honorable Donna E. Shalala
Secretary of Health and Human Services
200 Independence Avenue, S.W. Room 615F
Washington, DC 20201
Dear Secretary Shalala:
It is my understanding that the U.S. Congress is reviewing the effectiveness of the
Vaccines for Children Program. The March of Dimes has particular interest in this
program because our mission is to improve the health of babies by preventing birth
defects and infant mortality. Timely childhood immunizations can do both. Our history
includes efforts to prevent polio, as well as to eliminate rubella and the serious birth
defect congenital rubella syndrome. We also believe no babies should die of measles --
as many did in the 1990-91 epidemic.
When fully implemented, the Vaccines for Children Program would ensure that
poor and uninsured children have financia) access to all necessary vaccines. While rates
of childhood immunization for individual vaccines have improved over the last few years,
only two-thirds of children are fully immunized (4 DTP, 3 polio and 1 MMR) by their
second birthday.
The Federal childhood vaccine program funded through appropriations for local
health departments has long fallen short of the need. For example, before the Vaccines
for Children Program was initiated, the federal distribution for the Hib meningitis vaccine
was inadequate for three years after it was put on the market. Health departments had
to ration the vaccine, rather than protect all children.
The shortfall in public funds was related to steady increases in the price of
vaccines. At the same time, many uninsured working families paid double the public
price for vaccines in private physicians offices. When they could not afford these prices,
such families were sent to the already burdened health department clinics. The Vaccines
for Children Program can help families receive affordable immunization services from
their private pediatricians.
FROM 202-298-2964
05-03-95 12:45 PM
SENT BY:Xcrox Telecopier 7021 : 5- 3-95 ; 5:02PM :
94562878:# 7
MAY 03 '95 12:55 FR MARCH OF DIMES DC 202 296 2964 TO 6908168
P.83
The Vaccines for Children Program can both save money for federal and state
government and target needed immunizations to children who are uninsured and whose
families cannot afford the out of pocket costs for vaccines. The Vaccines for Children
Program provides relief to states, who can reallocate public health dollars for outreach,
education and services. The federal law also correctly protects states' rights to purchase
vaccines for all children at the Federal price.
It is important to remember that the Vaccines for Children Program was
developed as a bipartisan compromise, including elements from the original Clinton
Administration plan, as well as from bills introduced by Democratic and Republican
Senators in the 103rd Congress (S.733 and S.732 introduced by Senators Reigle and
Kennedy; and S.886 Introduced by Senators Danforth, Kassebaum, Durenberger, Gregg
and Bond).
As president of the March of Dimes, I urge you to work for continuation of the
Vaccines for Children Program so that the goal of immunizing all our nation's children
with age-appropriate vaccines can be reached by the Year 2000.
Sincerely,
Cenale House
Dr. Jennifer L Howse
President
FROM 202-288-2984
05-03-95 12:45 PM
FOR
SENT BY:Xcrox Telecopier 7021 : 5- 3-95 : 5:02PM :
94562878:# 8
MAY 03 '95 12:55 FR MARCH UF DIMES DC
202 296 2964 TO 6908168
P.04
Marchat
Denns
March of Dimes
Birth Defeats Foundation
National Government Affairs Office
1801 L truest K.W., Suite 290
Washington DC 20036
Telephone NR DOB HER
FAX X an 2054
May 3, 1995
The Honorable Bob Packwood, Chairman
Committee on Finance
United States Senate
219 Dirksen Senate Office Building
Washington, DC 20510
Dear Mr. Chairman:
It is my understanding that the U.S. Congress is reviewing the effectiveness of the
Vaccines for Children Program. The March of Dimes has particular interest in this
program because our mission is to improve the health of babies by preventing birth
defects and infant mortality. Timely childhood immunizations can do both. Our history
includes efforts to prevent polio, as well as to climinate rubella and the serious birth
defect congenital rubella syndrome. We also believe no babies should die of measles -
as many did in the 1990-91 epidemic.
When fully implemented, the Vaccines for Children Program would ensure that
poor and uninsured children have financial access to all necessary vaccines. While rates
of childhood immunization for individual vaccines have improved over the last few years,
only two-thirds of children are fully immunized (4 DTP, 3 polio and 1 MMR) by their
second birthday.
The Federal childhood vaccine program funded through appropriations for local
health departments has long fallon short of the need. For example, before the Vaccines
for Children Program was initisted, the federal distribution for the Hib meningitis vaccine
was inadequate for three years after it was put on the market Health departments had
to ration the vaccine, rather than protect all children.
The shortfall in public funds was related to steady increases in the price of
vaccines. At the same time, many uninsured working families paid double the public
price for vaccines in private physicians offices. When they could not afford these prices,
such families were sent to the already burdened health department clinics. The Vaccines
for Children Program can help familics receive affordable immunization services from
their private pediatricians.
FROM 202 290 2364
05-03-05 13:45 PM
SENT BY:Xerox Telecopier 7021 ; 5- 3-95 ; 5:03PM ;
MAY 03 '95 12:56 FR MARCH OF DIMES DL
¿CL
630
94562878;# 9
The Vaccines for Children Program can both save money for federal and state
government and target needed immunizations to children who are uninsured and whose
families cannot afford the out of pocket costs for vaccines. The Vaccines for Children
Program provides relief to states, who can reallocate public health dollars for outreach,
education and services. The federal law also correctly protects states' rights to purchase
vaccines for all children at the Federal price.
It is important to remember that the Vaccines for Children Program was
developed as a bipartisan compromise, including elements from the original Clinton
Administration plan, as well as from bills introduced by Democratic and Republican
Senators in the 103rd Congress (S.733 and S.732 introduced by Senators Reigle and
Kennedy; and S.886 introduced by Senators Danforth, Kassebaum, Durenberger, Gregg
and Bond).
As president of the March of Dimes, I urge you to work for continuation of the
Vaccines for Children Program so that the goal of immunizing all our nation's children
with age-appropriate vaccines can be reached by the Year 2000.
Sincerely,
ComperHause
Dr. Jerinifer L Howse
President
FROM 202-298-2954
05-03-95 12:45 PM
??!
SENT BY:Xerox Telecopier 7021 ; 5- 3-95 ; 5:03PM :
94562878;#10
MAY 03 '95 12:56 FR MARCH OF DIMES DC
202 296 2964 TO 6908168
P.06
Marchet
Thurs
Nuch of Dimes
Birth Defects Foundation
National Government Affairs Office
1901 L Street N.W., Suite 260
Washington DC 20030
Telephone an 659 1800
FAX me 206 2954
May 3, 1995
The Honorable Daniel Patrick Moynihan
Ranking Minority Member
Committee OR Finance
United States Senate
203 Hart Senate Office Building
Washington, DC 20510
Dear Senator Moynihan:
It is my understanding that the U.S. Congress is reviewing the effectiveness of the
Vaccines for Children Program. The March of Dimes has particular interest in this
program because our mission is to improve the health of babies by preventing birth
defects and infant mortality. Timely childhood immunizations can do both. Our history
includes efforts to prevent polio, as well as to eliminate rubella and the serious birth
defect congenital rubella syndrome. We also believe no babies should die of measles -
as many did in the 1990-91 epidemic.
When fully implemented, the Vaccines for Children Program would ensure that
poor and uninsured children have financial access to all necessary vaccines. While rates
of childhood immunization for individual vaccines have improved over the last few years,
only two-thirds of children are fully immunized (4 DTP, 3 polio and 1 MMR) by their
second birthday.
The Federal childhood vaccine program funded through appropriations for local
health departments has long fallen short of the need. For example, before the Vaccines
for Children Program was initiated, the federal distribution for the Hib meningitis vaccine
was inadequate for three years after It was put on the market. Health departments had
to ration the vaccine, rather than protect all children.
The shortfall in public funds was related to steady increases in the price of
vaccines. At the same time, many uninsured working families paid double the public
price for vaccines in private physicians offices. When they could not afford these prices,
such families were sent to the already burdened health department clinics. The Vaccines
for Children Program can help families receive affordable immunization services from
their private pediatricians.
PROM 202-298-2964
05-03-95
12:45
PM
SENT BY:Xcrox Telecopier 7021 : 5- 3-95 ; 5:04PM ;
94562878:#11
ITHT DO == 12.51 PR
The Vaccines for Children Program can both save money for federal and state
government and target needed immunizations to children who are uninsured and whose
families cannot afford the out of pocket costs for vaccines. The Vaccines for Children
Program provides relief to states, who can reallocate public health dollars for outreach,
education and services. The federal law also correctly protects states' rights to purchase
vaccines for all children at the Federal price.
It is important to remember that the Vaccines for Children Program was
developed as a bipartisan compromise, including elements from the original Clinton
Administration plan, as well as from bills introduced by Democratic and Republican
Senators in the 103rd Congress (S.733 and S.732 introduced by Senators Reigle and
Kennedy; and S.886 introduced by Scnators Danforth, Kassebaum, Durenberger, Gregg
and Bond).
As president of the March of Dimes, I urge you to work for continuation of the
Vaccines for Children Program so that the goal of immunizing all our nation's children
with age-appropriate vaccines can be reached by the Year 2000.
Sincerely,
Comporthose
Dr. Jerinifer L Howse
President
** TOTAL PAGE. 07 **
05-03-97 11:45 !!!
P:?
FROM 202-298-2964
MAY-04-1995 09:39 FROM
TO
94561715 P.01
STATEMENT OF
F.E. THOMPSON, JR., M.D., M.P.H.
STATE HEALTH OFFICER
MISSISSIPPI STATE DEPARTMENT OF HEALTH
BEFORE THE
COMMITTEE ON FINANCE
OF THE
UNITED STATES SENATE
MAY 4, 1995
MAY-04-1995 09:39 FROM
TO
94561715 P.02
Mr. Chairman and members of the committee, I am F. E. Thompson, Jr., M.D.,
M.P.H., Director of the Mississippi State Department of Health. Prior to assuming my
position as State Health Officer, I was State Epidemiologist and Chief of the Bureau
of Preventive Health Services, which included our immunization program.
As a practicing public health professional with continued direct involvement in a
statewide immunization program, I want to express my appreciation for the interest
and support being given children's immunization by the President and the Congress.
The increased resources already provided for childhood immunization are a clear
indication of both the President's and the Congress's intent to protect our children
against diseases no child should have.
CURRENT STATUS
Mississippi, a state with one of the lowest per capita incomes in the Nation, and one
with limited public resources to address the prevention of disease, has achieved one
of the highest immunization levels for its two year old children of any state.
Compared to a national level of at most 71.6 percent of children who have completed
their basic series of immunizations by the age of 27 months, Mississippi consistently
documents approximately 76.1 percent of its 27 month old children having completed
their basic series. One of our nine public health districts has already reached the goal
of 90%, and two others are above 80%.
We know our immunization levels with confidence because we perform an annual
statistically sound survey of two year old children's immunization levels. It is done
using a probability sample selected from the entire birth cohort of two years prior to
the year of study. The Immunization records of the sample children are then located
and examined so that we are able to demonstrate, with extraordinarily narrow
confidence intervals, what our immunization levels actually are. Very few other
jurisdictions perform such a statistically rigorous survey.
MAY-04-1995 09:40 FROM
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94561715 P.03
As deplcted in Attachment 1, approximately 80 percent of Mississippi children receive
all or most of their immunizations In health department clinics. Another five percent
receive their immunizations in community health centers and other publicly funded
clinics, and approximately 15 percent are immunized by private physicians. While we
do not suggest that this is the best approach in every state or even in most states, it
does demonstrate that immunization levels well above those found in most states can
be achieved largoly through public health clinics.
BARRIERS TO HIGHER IMMUNIZATION LEVELS
To achieve our goal of 90% completion by two years of age, we must look at the
major barriers that have prevented higher levels of completion. The cost of vaccines
has not been one of them. Mississippi's experience clearly demonstrates this. We
have accomplished the high immunization levels we have, and can reach our 90%
goal, without furnishing free vaccine to private providers. In analyzing the reasons
why 24% of our two-year olds are not fully immunized, we have not found the
availability of vaccine, or its cost, to be a significant barrier. MMR is currently the
most expensive vaccine we give, yet in 1993, 86% of Mississippi children had
received MMR by 27 months of age. Availability of vaccine is not the problem. Like
all states, we purchase our public health vaccines through federal contracts at prices
significantly below the retail prices paid by private providers. We have been able to
provide immunizations to any child in Mississippi who wants to receive them through
the health department at minimal charge ($5 per dose) for those who can afford it
and at no charge to those who cannot. We have had enough vaccine, and as long as
new vaccines and cost increases are provided for, we will have.
The real barriers are (1) the complexity of the vaccine schedule, (2) our failure to
track children's immunizations and remind parents of needed doses, (3) lack of
accessibility of clinics and staff to give the vaccine, and (4) our missed opportunities
to immunize many children we are already seeing.
2
MAY-04-1995 09:40 FROM
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94561715
P.04
By addressing these real barriers and developing activities to get vaccine out of bottles
and into children, such as reminder notices, outreach, checking records, and better
clinic hours, one of our public health districts raised completion levels for all two-year
olds from 58% to 80% in one year, without doing anything about the cost of vaccine.
The two most important barriers are actions not taken: Failure to track children's
immunizations and missed opportunities. Overcoming these two barriers would take
us to our national goal of 90% of children complete by age two.
Failure to Track Children's Immunizations
Because the immunization schedule for children is complex and requires at least 4 to
5 visits to complete, parents need help in knowing what shots their child needs, and
in remembering when the next ones are due. Immunization tracking systems or
"registries" can provide that help.
Mississippi has just implemented a computerized immunization tracking system or
registry. Its purpose is twofold. First, it makes available immunization records of
children to health care providers who see that child so that they can assess the child's
immunization status and provide any needed immunizations. Secondly, and much
more importantly, a registry allows us to track children's immunizations. We can then
send notices to parents of immunizations about to be due, send additional notices to
parents whose children fail to be immunized by a scheduled time, and identify children
who are falling too far behind in immunizations so that we can make phone calls or
home visits to get them back on schedule and protected.
Recalling children Is a critical element in increasing immunization coverage. As noted
in Attachment 2, in-1993, although only 76 percent of Mississippi two year olds were
fully immunized by their 27th month, another 16 percent needed only one more visit
to a clinic to complete their series. If we could have recalled these youngsters just
once, we would already have reached the 90 percent goal. We can do so if we
3
MAY-04-1995 09:41 FROM
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94561715 P.05
develop tracking systems that allow us to identify and recall them.
Missed Opportunities
The other major area of emphasis is to avoid missed opportunities to immunize
children. Missed opportunities fall into two main categories: 1) times when the child
is seen in a clinic for other services and immunizations are due according to the
schedule but the schedule is not checked and the child leaves without being
immunized; 2) times when the child presents in the clinic for an immunization or for
another service when the immunization is due and the provider realizes an
immunization is due, but defers the immunization for inappropriate reason, such as
"being on antibiotics" or a minor upper respiratory infection or any of numerous
"false" contraindications that do not really preclude immunizations.
At one of our largest Health Department clinics we found that 50 percent of children
being seen in that clinic had completed their basic series by 19 months of age, but
if all opportunities to immunize had been taken and none missed, the percentage
would have been 67 percent. This is illustrated in Attachment 3.
We have made it our policy in the Department of Health's clinics to assess a child's
immunization status on every encounter for any of our clinic services and to "stick 'em
while you got "em" if any immunizations are due. Minimizing or eliminating missed
opportunities is critical to raising our nation's immunization levels.
IMPLEMENTATION OF THE VFC
The main problems encountered with implementation of the VFC in Mississippi have
been the numerous changes in the program before it was implemented, the added
responsibility of the Health Department for distributing the VFC vaccine to providers,
and the lack of private provider participation. We sent out 1300 enrollment kits to
providers; as of today, 77 private providers have signed up.
4
MAY-04-1995 09:41 FROM
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94561715 P.06
The main success has been that we have at least implemented the program. Also, in
some states, state medicaid matching funds previously used to pay for vaccines which
VFC now covers have been made available for other uses.
EFFECT OF THE VFC ON IMMUNIZATION LEVELS
Even as originally proposed, the VFC would have had little if any impact in raising our
Immunization levels. The cost of vaccine was not the problem in the first place, and
making more vaccine available at public expense was not the solution. However, as
originally proposed, the VFC was at best overkill, and at worst wasteful, spending
a huge amount of money for a minimal impact on immunization levels. As it now
exists, at least in some states, the VFC itself stands to become a major barrier to
improving immunization levels, and is very likely to lower them.
The reason for this is the restriction of VFC vaccine use to Federally Qualified Health
Centers (FQHC's) for "underinsured" children, those who have health insurance which
does not cover vaccine. Such children are the majority of those we see in Health
Department clinics, and in most private practices. In Mississippi, as seen in
Attachment 4, 53% of children have insurance, but that insurance does not cover
vaccine. If those children have a private doctor, that doctor cannot give them VFC
vaccine; if they come to the Health Department, which has clinics in every county in
the state, we can't give them VFC. vaccine. Under the program as It now stands, their
doctor, or the health department must send them to a FQHC or give them non-VFC
vaccine. For the private doctor, this means charging the patient or absorbing the cost.
For the health department it is far more serious.
Vaccine for Health Department clinics has long been purchased with funds provided
through the CDC under section 317 of the Public Health Service Act. With the advent
of the VFC, 317 funds to health departments have been reduced, on the theory that
VFC will replace them. In 1993, Mississippi received $3.2 million in VFC funds; in
1994, we got $3.9 million; for 1995 our allocation is $1.7 million. Meanwhile, we
5
MAY-04-1995 09:42 FROM
TO
94561715
P.07
have $3 million for VFC, but we can't use that vaccine for most of the children we
see. We cannot immunize half the children coming to us with the 317 dollars
available. And they do come to us. They come for the WIC program; they come for
well child care; they come for immunizations because our clinics are convenient.
Under the VFC as it now stands, we will be faced with turning these youngsters
away. Rather than avoiding missed opportunities, the VFC will create them, and
multiply them.
The VFC as presently constituted threatens to result in a working, successful
immunization system being dismantled. It is a major concern on our part that federal
efforts to increase immunization levels do not tear apart a system which is working
well and which, if continued and improved upon will take us to the 90% goal before
many other states.
The restriction of VFC vaccine for the majority of children to FQHC's is the reason
many of our private providers have chosen not to participate in the program. Citing
the fact that well over half their patients have insurance that does not cover vaccine,
they tell us that it just doesn't help them very much, and it's not worth the trouble.
RECOMMENDATIONS FOR CONGRESSIONAL ACTION
1 recommend that this committee and the congress consider the wisdom of the VFC
as a whole, in addition to examining the mechanics of its implementation and
operation. If the VFC is to be left in place, I strongly urge this committee to
recommend that the restriction of the use of VFC vaccine for underinsured children to
FQHC's be removed. If it cannot be removed, at least extend the ability to give VFC
vaccine to underinsured children to Health Departments. Otherwise the VFC, a well
intentioned program, will do more harm than good.
Another critical action from our State's perspective is to restore funding of the 317
program to its pre-VFC levels. Finally, and also critical, if the VFC is left in place, any
6
MAY-04-1995 09:42 FROM
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94561715 P.08
changes made to it should preserve the ability of states to purchase vaccine at federal
contract prices using state funds, at least for use in Health Department clinics. These
two actions will at least insure that existing, working immunization programs are not
impacted adversely.
7
Source of Immunization
Mississippi, 1994
MAY-04-1995 09:43 FROM
5%
15%
TO
80%
State Dept. of Health
Private Providers
Community Health Ctrs.
60'd 94561215
Attachment 1
Immunization Levels for Two-Year-Olds
by Number of Additional Visits Required to Complete
Mississippi, 1993
MAY-04-1995 09:43 FROM
None 76%
Three 2%
Two 5%
TO
Four 1%
One 16%
94561715 P.10
Source: Mississippi Immunization Survey of Two Year Olds
Attachment 2
HINDS COUNTY, MISSISSIPPI HEALTH DEPARTMENT CLINIC
Children Already Being Seen, 1993
19 Month Olds
100%
MAY-04-1995 09:44 FROM
80%
67%
Missed
Percent Complete
60%
- Opportunities
50%
Eliminated
40%
TO
Actual
20%
0%
94561715 P.11
Source: Hinds County Health Department Clinic Audit, 1993
Attachment 3
Insurance Coverage
Mississippi, 1994
MAY-04-1995 09:44 FROM
Medicaid
Insured
29%
1%
Uninsured
16%
TO
Native American
Underinsured
1%
53%
94561715 P.12
Source: Governor's Commission On Health Care Reform
Attachment 4
ID:
MAY 03'95
7:35 No. 003 P.02
DEAFT . 6:10PM, 5/3/95
Doc. 51971
STATEMENT OF
DAVID SATCHER. M.D., Ph.D.
DIRECTOR
CENTERS FOR DISEASE CONTROL AND PREVENTION
BEFORE THE
COMMITTEE ON FINANCE
U. S. SENATE
MAY 4, 1995
ID:
MAY 03'95
7:36 No. 003 P.03
Mr. Chairman, I am Dr. David Satcher, Director of the Centers for
Disease Control and Prevention (CDC). I am accompanied by Dr.
Walter Orenstein. Director of coc's National Immunization
Program.
Thank you for the opportunity to appear before this Committee to
discuss childhood immunization I am pleased to be here LU tell
you about the progress WA have made since October 1 when the
Vaccines for Children (VFC) Program became operational, according
to law, and to clarify issues that have been raised in the
process. Your letter asked that we bring you up-to-date on
several issues, including successed and problems of VFC
implementation. barriers to Immunization, and impact of VFC on
immunization rates.
IMPLEMENTATION OF THE VFC PROGRAM
The VFC Program began only 7 months ago. We have made
significant progress,
VFC is operating in all States.1
Vaccine purchase contracts were signed with the
manufacturers to provide vaccines for eligible children at
1 Alaska, which already delivers vaccines to all providers
in the State, 10 not participating in the VFC program.
Alaska la able to use other Federal vaccine funds to
purchase all vaccines for all children in the State.
1
MAY 03'95
7:36 No 003 P.04
ID:
discounted CDC contract prices for all veccines routinely
recommended for children.
C
State Health Departments are rapidly enrolling public
providers into the program. As of March, over 8,100 public
sites, such as local public health departments, community
health clinica, maternal and child health olinics, and
public hospitals. in every State are participating in the
program.
0
Private providers are also being rapidly enrolled. As of
March, over 21,000 private provider sites, many with
multiple physicians par site, have enrolled so far. This is
a 32 percent increase in private provider sites since the
program began. We expect to increase the number of private
providers enrolled as more States develop systems to deliver
vaccine to private providers.
o
The vaccine ordering system is working well. Over 1,700
bulk orders have been processed, totaling over $150 million
in vaccine.
o
Since October, over 13 million doses of children's vaccines
have been shipped through the VFC program.
2
MAY 03'95
7:37 No.003 P.05
ID:
The good new# 1s that we are making progress towards our goal of
Immunizing 90 percent of the nation's children against vaccine-
preventable diseases. Our most recent immunization coverage
information, from the first quarter of 1994, indicates that We
are at record high levels of immunization coverage for two-year-
old children. I believe if we stay Focused, we will achieve our
yoal.
We still, however, have work to do. Our data tells us that about
600,000 to 2 million of our nation's children between 19 and 35
months of age still had not received recommended vaccinations
against specific diseases. For example, about 2 million of these
children had not received the full series of vaccinations. About
1.4 million of these children had not received necessary polio
vaccinations. Table 1 presents these most recent vaccination
levels and the associated estimates of children who have not
received all recommended vaccines.
3
MAY 03'95
7:37 No 003 P.06
ID:
Table 1
Vaccination Levels and Estimated Numbers of Two Year Old*
Children Not Fully Protected in the U.S., 1st Quarter 1994
Vaccine
Vaccination
Estimated Numbers of Children
Levels
NOL Fully Protected
(Percentages)
DTP 3+
87
800,000
DTP4
67
1,900,000
OFV 3
76
1,400,000
MMR
90
600,000
Hib 3+
71
1,700,000
4DTP/3QPV
66
2,000,000
/IMMR
* Children 19-35 months old.
Note (1) : A "+" next to a vaccine indicates 3 or more doses. For
example, DTP 31 1s receipt of 3 or all 4 recommended DTP doses.
Note (2) : Hepatitis R, although a recommended childhood vaccine,
1s not included in the tablo. The coverage for Hepatitis B was
only 26%, leaving 4.3 million children not fully protected.
However, many of these children were born before the Hepatitis B
recommendations were in effect.
Recognising that there are multiple barriers to childhood
immunization, CDC and its State and other partners. developed a
comprehensive approach to increase and sustain these percentages.
The Childhood Immunization Initiative (CII) was launched in carly
1994. CII includes five key strategies that will 1) improve the
quality and quantity of vaccination delivery services, 21 reduce
4
MAY 03'95
7:37 No 003 P.07
ID:
vaccine costs for parents, 3) increase community participation,
education, and partnerships. 4) improve the monitoring of disease
and vaccination coverage, and 5) improve vaccines and vaccine
use. The VFC Program, one component of the CII, was designed as
one of these key strategies to address immunization barriers.
The VFC Program is important for several reasons, Including
allowing eligible children to obtain immunivations in their
medical homes,
providing greater access to vaccinos, and
forging public/private partnerships to get more children
immunized.
Cost is a barrier that contributes to delays in achieving full
immunization of preschool children with today's vaccines. The
cost of the vaccine series has increased about 10 fold in the
past 12 years. This is the result of more doses recommended for
older vaccines. new vaccines added, excise taxes. and increases
in the COSE of the old vaccines. Regardless of the cause of the
increased cost of the vaccine series, when parents must Dav about
$270 in vaccine costs and almost an equal amount in
administration fees to have each child fully vaccinated, it
stands to reason that parents without adequate insurance seek
immunizations, not from their private doctor, but from public
health clinics where the vacuine is free or available at nominal
cost. Having to make the extra visits to these public clinics
5
MAY 03'95
7:38 No.003 P.08
ID:
can delay the timely immunisation of children.
SUCCESSES AND PROBLEMS IN THE VPC PROGRAM
There have been many successes in the implementation of the VFC
Program. Through the purchase of vaccines at discounted CDC
contract prices. the VFC program helps assure cost savings to
Medicaid. Before VFC, the cost of vaccines for most children or
Medicaid was based on higher catalogue prices. VFC allows States
to purchase their vaccines at discounted CDC contract prices
without having to negotiate these prices directly with
manufacturers. By shifting children on Medicaid from higher
catalogue vaccine prices to lower CDC contract prices, millions
of Federal and State taxpayer dollars will be saved. The
catalogue price for the total series ot vaccines is about $270,
while the CDC price is about $130. California alone has
estimated that it saves $40 million a year from the ability to
purchase vaccines at the lower CDC contract price.
Transition
Of course. we know that addressing cost alone will not solve the
underimmunization problem. It is clear only a comprehensive
approach with interventions against multiple barriers is likely
to raise and sustain immunization levels among preschool children
in the D. S.
Transition
cornerstone of the VFC Program 15 the forging of new
6
MAY 03'95
7:38 No 003 P.09
ID:
partnerships with private providers. Support from public and
private medical communities at the National, State and local
level have strengthened our efforts to immunize children.
\Total Federal and State vaccine expenditures will not be much
Transpon:
more when VFC is fully operational than what they were before.
VFC allows us to buy more llfe-saving vaccine for About the same
amount of money. This is because vaccine purchase under the
"317" grant program has been significantly reduced Also,
Medicaid vaccine (which nexus up well over one-half of VFC
vaccine) is now purchased at discounted CDC contract prices,
rather than more expensive catalogue prices.
Most State Health Departments strongly support the VFC program
and value its benefit co individual children and communities as a
whole. Several States, including California. Goorgia, Oregon,
South Dakota and Rhode Island, have reported to the Association
of State and Territorial Health Officials that, without the VFC
program, their immunization efforts would cuffer "catastrophic"
consequences. Some States, such as Connecticut, Kentucky, Idaho,
and Michigan, advised they would have to limit the availability
of some vaccines, including the Hasmophilue Influensee type b and
Repatitis B vaccines, and South Carolina reported that
immunization rates would plumnet.
The major private physician associations and tens of thousands of
7
MAY 03'95
7:39 No.003 P.10
ID:
private physicians are supporting the VFC program, CDC has made
it at priority to listen to these groups' views and develop an
acceptable and workable program. It should also be remembered
Usat not all private physicians, such as those that only serve
children with insurance, would see a VFC benefit to their
practices.
while some physicians remain ckeptical, primarily because of the
perceived paperwork burden, we expect continued increases in
enrollment as more States establich delivery systems to private
providers. and the facts about the operation and benefits of the
VFC program become more recognized.
The VFC program has strengthened and institutionalized the
partnership between public and private medical communities at the
National, State, and local level. More than 30 private medical
professional associations are working with us to implement the
VFC program. These groups include the American Medical
Association, the American Academy of Pediatrics (AAP), the
American Academy of Family Physicians, the American Osteopathic
Association, the National Medical Association, and the
Interamerican College of Physicians and Surgeons. Dr. Frances
Rushton, President, South Carolina Chapter, AAP, recently told my
staff that the VFC partnership has been the single greatest
public/private partnership effort in his medical career.
8
MAY 03'95
7:39
ID:
PROBLEMS IN THE VFC PROGRAM
The complex nature of the implementing legislation and the
relatively short time allowed to kick-off the VPC program have
complicated ice implementation. I would like to address two
issues: accountability systems and vaccine delivery to private
providers in some States.
VFC Accountability Systems
GAO has expressed doncern about accountability. Financial
accountability is an essential component of the VFC program.
States have primary responsibility for accounting for vacoine.
States have over 30 years experience managing immunization
programs and are in the best position to account for vaccines
bocause of their knowledge of unique circumstances and provider
practices,
It is erucial to maintain the right balance between effective
accountability and provider participation. Private provider
organizations have warned us that paperwork would keep physicians
from enrolling. If providers had to report each immunization
transaction, they would be burdened with filling OUL and sending
in over 14 million pieces of paper a year. CDC has been
reluctant to impose such bureaueratic accountability
requirements. In building an effective accountability system,
several activities are underway, including the development of
9
MAY 03'95
ID:
state accountability plans, monitoring orders, and the submission
of three annually required forms. Overall. CDC fools it has
instituted the appropriate balance between accountability and
provider participation.
Vacuine Delivery to Private Physicians in Some States
CDC initially proposed distributing vaccine to private physicians
in selected States through a national distribution center, or
requested by most States. In September 1994, CDC began
negotiations with vaccine manufacturers anticipating delivery to
private physicians in December. on April 10, CDC had to
discontinue these negotiations. Although final agreement was
reached with one manufacturer, time was not available to reach
agreements with remaining manufacturers. CDC is planning to meet
with interested parties to determine how best to conduct vaccine
delivery.
Despite this, VFC vaccine is being delivered to tens of chousends
of public and private providers. Forty-nine States are
delivering vaccines to public clinica, which account CUS about 50
percent of immunizations nationwide. As of March 30, 35 States
had informed CDC they were delivering vactine to onrolled private
providers. At least 10 of the 14 remaining States reported they
4 remaining
plan to begin dolivering vaccine this year.
states will delivery. set up
10
MAY 03'95
202-000-6598:712/18
ID:
BARRIERS TO IMMUNIZATION
There are numerous risk facture for failure to vaccinate children
on time which have been identified from research and from the
experience of health professionals directly involved in providing
vaccines to infanto and children.
Recent studies are also emphasizing the crucial role of the
provider in improving immunization coverage. Children are
seeking health care, but that health care may not be translated
into high immunization coverage. Based on a study of the
immunization records of children in 5 public health clinics
around the United States, the average number of visits during the
first 2 years of life ranged from 5 to 15, yet coverage for the
complete vaccination series ranged from only 18% to 61%. The
number of health care contacts should have been adequate to
provide all vaccinations needed in the first 2 years of life.
Providers have a crucial role in making cure all opportunities to
vaccinate are taken, in reducing obstacles or barriers parents
may face in getting their children vaccinated, and stimulating
parents to return for immunization visits. The potential impact
of taking advantage of all vaccination opportunities was studied
in 4 inner cities. DTP-4 coverage could have improved from 8
11
MAY 03'95
7:40 No 003
ID:
percentage points in Los Angoles to 16 points in Baltimore.
Another serious barrier is the condition of the public health
system. About 50% of immunizations in this country are given in
public clinics. A variety of impediments exist to delivering
vaccines in these public settings, including insufficient clinic
staff, inconvenient clinic hours, or lack of recall systems.
Also, vaccine cost, by increasing referrals from private LU
public providers, further stresses these delivery systems.
Federal infrastructure grants address these problems. (See Table 2)
Table 2
Grant Funding for Infrastructure Enhancement (FY 93-FV 36)
($ in millions)
FY 93
FY 94
FY 95
FY 96
Approp.
Approp.
Approp.
Estimate
Infrastructure
$45
$129
$109
$108
That's why
Incentives
$ 2
$33
$33
$33
TOTAL
$45
$162
$141
$141
my
Immunization must be a shared responsibility of both providers
from
and parents. Data from a variety of studies indicate the vast
45 to
majority of parents want to immunize their children. But parents
141
do not understand the complexity of the immunization schedule and
the fact that more doses and visits are needed now, than when
13
MAY 03'95
7:41 No.003
ID:
they were children. Frequently, parents have believed that their
children were fully immunized, when they were not. Through
community outreach and education, parents need to understand that
immunizing a child requires at least 5 visits to providers, and
that they should have the immunization status of their child
checked at every health care contact whether the child is 111 or
well.
with increasing numbers of available vaccines complicating the
immunization schedule, parents and providers need help in keeping
track. Computerized, State-based immunization registries, when
Again,
operational, will romind parents when immunizations are due, or
overdue, and assist providers in determining the immunization
we this.
needs of their patients, old or new. at the time of each visit.
Some States are now developing these systems. One example is
Delaware. which has developed a statewide registry system for
public and many private providers.
Numerous surveys of both practitioners and health departments
have documented increasing referrals of patients from their
primary care providers or medical homes to public clinics, with
cost to the patient as the most important reason. A 1992 AAP
study revealed 55 percent of pediatricians refer some or all of
their patients for Immunizations to A public provider. A 1992
North Carolina survey documented 93% of physicians referred
patients to health departments for immunizations. A recent
13
MAY 03'95
7:41 we
600° °N
ID:
survey of pediatricians and family practitioners in New York
found that 5U percent referred all or some of their patients for
vaccinations, generally to public health clinics, Finally, in a
1993 survey of 538 families attending public immunization clinics
in California, Lieu and colleagues concluded that financing
reform has the potential to improve vaccination rates, if it is
combined with improved parent education, and reduced non-
financial barriers to immunization.
14
ID:
MAY 03'95
7:41 No 003 P.17
Clearly, cost contributes to making immunization harder to obtain
and plays a role in the delay in getting children fully immunised
according to the recommended schedule.
IMPACT OF VFC ON IMMUNIZATION RATES
Childrens health will improve as 4 result of VFC. It will be
difficult to document how the VFC program alone will increase
immunization rates. In its July 1994 report on the VPC program,
GAO documented that it will be extremely difficult to assess
VFC's impact since VFC is only one of the CII's five components.
CDC 16 currently developing an avaluation plan to attempt to
address this issue, which we will provide this summer.
The VFC Program will definitely improve the health of our
Nation's children. despite the difficulty of documenting
increases in immunization rates directly related to VFC, this
1a
because the vre program speeds up the provision of new and
improved vaccines to eligible children Some Seates would not be
able to offer heae new vaccineo to childr en without vre covering
substantial persion of the children in need. Alse, The VFC
program allows eligible childron to obtain Immunization in their
medical home where they can receive other components of health
promotion and disease prevention.
15
MAY 03'95
7:42 No 003 P.18
ID:
CONCLUSION
Immussization represents one of the most, if not the most, cost-
effective public health intervention. nowever, vaccines can only
be as good as the system we have to make sure children in need
get them when they need them. There is no magic bullet to solve
the problem. No one approach, such as school laws, will suffice
for the preschool population. Wo are close enough to our goals
to be convinced we can reach them with intensified use of our
current comprehensive strategy.
This nation has too often responded Lo crises rather than
preventing them. We need a system that will assure that children
born yesterday, today, and in the future will be vaccinated at
the time in their lives when vaccines can prevent the greatest
amount of disease. This cystem must function not only during and
immediately after the threat of epidemic disease. such as
occurred after the recent measles resurgence between 1989-1991;
but, more importantly, the system must function during the period
of absence of disease which often lasts for many years after an
epidemic. Never again should spidemics be the primary motivation
of immunization efforts.
The CII is designed to build this disease prevention system by
enhancing vaccine delivery infrastructure, building partnerships,
involving the community. establishing data systems to help
16
ID:
MAY 03'95
7:42 No 003 P.19
parents and providers romember when immunizations are due, and
much more. If we are to prevent disease, we must build a system
that has secure vaccine financing, not only for today's vaccines,
but tomorrow's as well. VFC does that with the added benefit of
returning children to their medical homes where they can get sn
many other preventive services. such as growth monitoring.
screening for anemia, and much morc. The VFC is a major step
forward in improving the health of our children. and the CDC 15
committed to doing its best to fully implement the program to
gain its full benefits.
17
002
05/03/95 13:52
212 535 7488
CHF
TESTIMONY TO
THE UNITED STATES SENATE COMMITTEE ON FINANCE
CHAIRMAN, HONORABLE BOB PACKWOOD
MAY 4, 1995
THE CHALLENGE OF IMMUNIZING AMERICA'S CHILDREN:
MEDICAL HOMES AND THE VACCINE FOR CHILDREN PROGRAM
By:
Irwin Redlener, M.D., F.A.A.P.
President, The Children's Health Fund
Director, Community Pediatrics
and the New York Children's Health Project
Associate Professor of Pediatrics
Montefiore Medical Center - Albert Einstein College of Medicine
317 East 64th Street
New York, NY 10021
(212) 535-9707
003
05/03/95
13:53
212 535 7488
CHF
Testimony - 5/4/95
Irwin Redlener, M.D.
Senate Finance Committee
Chairman Packwood, members of the committee, I am here to support
the Vaccines for Children Program - but qualify this support based
upon certain concerns which must be addressed by introducing a few
important modifications. In general I am suggesting three over-
arching goals for the program:
1. As increasing attention is paid to budget deficits and state
versus federal control of public programs, we need to protect the
integrity of the VFC program and health care access for children.
The national agenda for children should not be undermined by
multiple state interpretations of what America's children need.
And, VFC should not be endangered by limitations related to
possible fundamental changes in Medicaid structure.
2. We must safeguard against unanticipated consequences of the
program as it is currently organized - including the use of
precious resources in ways which will not accomplish the goals of
VFC in the most efficient manner possible.
3. Conversely, we need to maximize all available resources -
including those provided through VFC - SO that the program targets
the children most in need with expenditures targeted to address
their specific barriers to health care and immunizations.
I am Dr. Irwin Redlener, director of community pediatrics and
associate professor of pediatrics at the Montefiore Medical Center
and Albert Einstein College of Medicine in New York. I have had
some 25 years experience in delivering health care and developing
programs for disadvantaged children.
I am also president of the Children's Health Fund, a foundation
responsible for establishing comprehensive pediatric programs for
some of the most medically underserved children in the nation,
including the children of homeless, migrant and otherwise severely
disadvantaged families in a wide range of communities.
Children's Health Fund programs operate in New York City; Newark,
New Jersey; Dallas, Texas; rural Mississippi; West Virginia; South
Florida; South Central Los Angeles; and Washington, D.C. These
programs have, to date, provided nearly 180,000 medical primary
health care encounters to our designated target populations.
The projects included within our network take children who have had
very little organized, quality health care and provide them with
care that is delivered by medical teams who are committed to
quality and continuity.
1
05/03/95
13:53
212 535 7488
CHF
004
Testimony - 5/4/95
Irwin Redlener, M.D.
Senate Finance Committee
We ascribe to a notion that the care all children receive should be
the kind of care we expect for our own children. This care should
be comprehensive, preventive and organized. Immunizations should
be administered at a place where the rest of their health care is
delivered; where follow-up vaccinations and follow-up for medical
problems can be tracked and managed. Where, if needed, specialty
care and hospital care can be coordinated and ensured.
Pediatricians refer to this kind of care as being provided in a
"medical home." It is the appropriate way to do what's right.
It's what all children deserve to have.
Children without a medical home may get health care, but it is the
worst kind of episodic, fragmented and expensive medical attention
in emergency rooms and drop-in clinics. This kind of care
typically entails little or no follow-up; and, it often does not
happen until illness has progressed too far.
In other words, medically homeless children get the wrong kind of
care, in the wrong places, at the wrong time. It is precisely
these children, without regular, dependable access to primary care
that are most likely to be underimmunized.
Conversely, the most important piece of evidence that a child is
medically underserved is underimmunization.
In fact, our programs provide medical care to some of the most
medically underserved children in the United States. For the
homeless and extremely indigent children cared for by our flagship
mobile unit program, the New York Children's Health Project, the
immunization rates are devastating:
Some 90% of our pediatric patients, on their first visit to our
program are behind in - or cannot document - their routine
immunizations.
This is an extraordinary indictment of the health care system for
indigent children and is, to our knowledge, one of the absolute
worst immunization situations in the United States.
Actually, in all of our sites, rural and urban, immunization rates
are terrifyingly low and, importantly, reflective of the sorry
state of the child health safety net in the United States. It is
my opinion, that because of factors ranging from lack of health
insurance to severe maldistribution of health professionals, at
least 15 million children under the age of 18 years lack
2
005
05/03/95
13:54
212 535 7488
CHF
Testimony - 5/4/95
Irwin Redlener, M.D.
Senate Finance Committee
appropriate access to appropriate health care.
I need to emphasize this reality: in terms of the most significant
IN
causes for the nation's problems around immunizing our children,
the cost of vaccine is not a major factor. Rather, it is lack of
city
access to a medical home type of health care relationship and the
absence of a functioning child health care safety net in this
country which are overwhelmingly responsible for our seeming
Designed to
inability to consistently protect our children through on-time
immunizations.
ANA imm.
to extent they have a med. home keeps them there
chridren
The Vaccine for Children Program (VFC) is clearly based on an
in them
med home. med home.
essential and laudable principle that all children need to be
immunized in an appropriate and timely manner. Our country cannot
Steps
afford otherwise. President Clinton and his entire administration
toward goal.
are committed to this goal and it needs to be achieved.
We are, therefore, strong supporters of the VFC but have insisted
that it be modified in several important ways in order that there
is some reasonable chance of the program realizing significant and
sustained improvements in the nation's immunization completion
rates.
Modifications are necessary because of certain problems and issues
which have become apparent as the program unfolds.
I would like to share with you my four principal concerns and
specific recommendations to re-shape VFC:
All states reported that
kids still Face barriers
Concern #1
But fact that vaccines are free is
essential.
George Washington University's Center for Health Policy Research
recently reported a study of immunization issues in 12 states where
there is universal purchase of vaccine for all children. In these
What
states, cost has been eliminated as a factor in underimmunization.
However, this study verifies our clinical experience in providing
NY
immunizations and primary care to underserved children around the
Audy.
a
what
U.S. VFC does virtually nothing to increase immunization rates for
the millions of children who have no regular place for health care.
These are the children who really need assistance in getting and
sustaining up-to-date immunizat They need medical homes.
You might look at the issue in this way: underimmunization is a
speak about it
3
in terms success of
NY
05/03/95
13:54
212 535 7488
CHF
006
Testimony - 5/4/95
Irwin Redlener, M.D.
Senate Finance Committee
symptom of lack of access to relevant pediatric health care. The
real "treatment" for this problem is guaranteeing access to
comprehensive health care where immunizations can be given over
time and on-schedule.
without d was
For the 15 million medically underserved children in the United
States the total amount of funds including the VFC program, Section
a home
317 and other public sector initiatives is insufficient to meet
existing needs. However, right now I am concerned that the
relationship between funds spent on vaccine purchase versus new
Need to
health provider capacity for disadvantaged children is not in
focus infra on Forl
appropriate balance.
Recommendation:
Focus CIFINEVA. on has
Congress needs to safeguard the total expenditure for
what done for
vaccine-related programs SO as not to jeopardize the
long-term national agenda for children. But, tax dollars
should not be used to purchase or subsidize vaccines for
families with sufficient income or insurance coverage.
These dollars should be re-directed to providing access
How this does fit of
to health care for as many medically underserved children
as possible. This means that what is really needed is
money for infrastructure, that is, new capacity to
idea
provide comprehensive, primary health care - while
medical home?
ensuring that funds to provide vaccines are always
sufficient to meet the needs of the children identified
as "at risk.
1
to
$ 141 -
Fed
spending
213%
from
increase.
Concern #2:
The VFC purchase and distribution plan helps families who have a
regular source of health care - pediatrician, family physician,
clinic, etc. - but cannot afford or are not covered for vaccines in
that setting. Some are directed to use public health clinics,
thereby fragmenting care. Studies have shown that VFC can help
many of these families. But under current VFC guidelines, there is
no limit to or monitoring of under what circumstances and for how
long these families would be eligible for free or subsidized
vaccine. In addition, certain VFC provisions permit states to
Dr.has
inappropriately use public funds to provide vaccines for insured or
non-needy children.
to verify
making you account. the GAO point?
4
what guidelines ?
Are
007
05/03/95 13:55
212 535 7488
CHF
Testimony 5/4/95
Irwin Redlener, M.D.
Senate Finance Committee
Recommendation
VFC should not offer opportunities for states
to use limited public resources to provide
free or subsidized vaccines to non-needy or
insured patients. In addition, VFC funds
should only provide vaccine to families until
Medicaid or private insurance coverage is obtained.
Concern #3
The VFC program is, of course, a great assistance to private
physicians and their patients since it eliminates the need to
utilize public clinics for vaccinations. Yet, although the private
practitioner benefits from the VFC as a government subsidy, private
doctors may still refuse to provide subsidized vaccine, or any
health care, to Medicaid or low-income patients - precisely the
children who are most in need.
Recommendation
Physicians or clinics participating in any
aspect of VFC should be required to accept
children covered by Medicaid, children who are
uninsured or those who are otherwise unable to
obtain appropriate health care.
Concern #4
Again put in more positive
terms. Stara we
The VFC program discourages insurance companies from including shid
responsibility for the cost of vaccines will simply be assumed by
immunizations in their family coverage. Companies may surmise that req.
a tax-supported program.
Ins.cos Ins. COS
Recommendation
to cover.
All insurance policies covering families,
whether fee-for-service or capitated premium
based, should be required to include all
recommended vaccines for children.
Members of the Committee:
5
008
05/03/95 13:55
212 535 7488
CHF
Testimony - 5/4/95
Irwin Redlener, M.D.
Senate Finance Committee
As I stated earlier children need real medical homes. If every
child in this country had a medical home, we would not have the
unconscionably low immunization rates we experience in rural and
urban areas around the country.
We need VFC. But it must be modified so that it can really take on
and solve one of the most important challenges of our time.
Finally, it is my hope - and that of virtually every health
professional and provider organization - that we can find a way to
make sure that every child in the United States has access to
appropriate and essential health care.
At the end of the day, it is health care, not vaccines, that should
be guaranteed for children by government.
I know that know that the President and the Administration are
deeply committed to VFC and access to health care for the nation's
children.
Our job now is to make the adjustments in an important program
that will permit it to function with maximal impact and in the
spirit intended by its original drafters. In this day and age,
where ever more children are vulnerable, endangered and facing an
uncertain future, making VFC as effective as it can possibly be is
the least we should do.
Thank you.
###
6
CLINTON LIBRARY PHOTOCOPY
Name
Dat.
Eric Moise
6/16/2000
OA # BS33
NARA# 109.33