While child immunization coverage remains high nationally, the spread of misinformation has reduced vaccination rates in some communities, putting them at risk of vaccine-preventable diseases. State health and Medicaid departments, which are responsible for vaccinating their residents, are working to counter misinformation and protect public health along with schools, pharmacies, and primary care providers.
Alabama employs a multifaceted approach to boost immunization rates among its Medicaid, public, and privately covered populations. The state’s strategies include various payment and reimbursement incentives, reporting protocols, and cross-agency partnerships.
This blog highlights how California’s health-related agencies collaborated to increase the state’s childhood immunization rates.
Vaccines are a critical public health tool used to help prevent deadly diseases, such as polio, measles, mumps, and smallpox, but they can also save states money. According to estimates:
Of 4.3 million US infants born in 2009, vaccines will prevent 40,000 deaths and 20 million illnesses over their lifetimes;
The US Centers for Disease Control and Prevention (CDC) officials estimate that vaccinating children born between 1994 and 2018 has saved the United States about $300 billion in direct medical costs and $1.38 trillion in total costs.
Over the last several years, Alabama has employed multiple state policy strategies and incentives to boost its immunization rates across Medicaid, uninsured, and privately insured populations alike.
The state’s innovative approach includes forming partnerships between state agencies, including health, justice, and education departments and the state’s Medicaid agency. Alabama has strong incentives to improve vaccination rates among its citizens, especially children and those covered by its Medicaid program.
As of 2017, Alabama’s combined seven-vaccine series coverage rate among children ages 19 to 35 months was 71.1 percent, higher than the 2018 national average of 70.4 percent. And, as of July 2018, Alabama’s performance rate for adolescent immunizations coverage was 73.9 percent- higher than the national average of 70.3 percent. To continue to improve its immunization levels and work towards the Healthy People 2020 goals, Alabama uses the following levers.
Comprehensive coverage: The Alabama Medicaid Agency (AMA) has identified immunizations as a critical component of the well-child check-up under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Under current EPSDT requirements, AMA recommends providing immunizations to children at the same time as other services are provided during a well-child visit, with the goal of preventing fragmentation of services. AMA requires immunization records be updated in accordance with the Advisory Committee on Immunization Practices’ recommended immunization schedule. AMA also offers care coordination services to EPSDT providers designed to help office personnel with identifying, contacting, and coordinating with children who are behind on their immunizations.
The Alabama State Board of Health requires parents or guardians of all children in childcare centers or enrolled in kindergarten through 12th grade to submit a Certificate of Immunization (COI) demonstrating that their children are up to date on their required vaccinations. Children who receive an Alabama Certificate of Medical Exemption from a licensed medical authority or are approved for an Alabama Certificate of Religious Exemption by their county health department may submit these in place of the COI. Religious exemptions cannot be issued to higher education institutions.
Vaccine availability and access: Alabama has several initiatives to increase availability of vaccines using partnerships between various state agencies. In 2017, the Alabama State legislature passed a joint resolution urging the State Department of Education and the Alabama Department of Public Health (ADPH) to encourage all schools to participate in a school-based vaccination program. ADPH also works with corrections facilities to help justice-involved individuals obtain vaccines through 317 funds. Allowing the justice system to vaccinate individuals expands this under-vaccinated population’s access to immunizations. Additionally, Alabama allows multiple types of providers (all physicians, nurse practitioners, physician assistants, and pharmacies) to register as Vaccines for Children (VFC) providers, which also expands immunization access.
Payment and reimbursement: AMA uses a fee-for-service payment strategy to encourage providers to vaccinate at appropriate ages. Immunizations are two of eight provider metrics used by the Alabama Coordinated Health Network program to determine a primary care physician’s quarterly bonus payment. Additionally, as of October 2019, AMA changed pharmacy vaccination administration billing requirements to allow pharmacists to submit both the vaccine and administrative cost of the vaccine on the same claim.
Reporting: During the 2019 legislative session, Alabama introduced a bill that would require health care providers to report vaccines to the immunization registry (ImmPRINT) and require providers to review the registry before the vaccine is administered. (The bill did not pass during the 2019 legislative session, and has been reintroduced in 2020.) The Alabama Department of Public Health (ADPH) has also been working with the CDC in a multi-state community of practice (CoP) focused on identifying, recruiting, and training providers to report their immunization data to the immunization registry. During the CoP, ADPH found that giving providers their own immunization data helped to improve their data quality and improve immunization efforts.
Through the CoP, ADPH created electronic data exchange interfaces, developed outreach reports for providers with coverage data, and deployed field staff for VFC providers to discuss how to improve coverage assessment and rates. In addition to these changes, ImmPRINT now publishes Alabama state and county vaccine coverage rates. All health care providers who immunize children up to age 18 can receive a tailored report that compares vaccination coverage across age ranges and vaccinations to show how the practice compares to county and state rates.
By using strategic levers Alabama has created and strengthened partnerships and programs within the state to improve overall immunization rates for Alabamans and increase vaccine access for populations with traditionally low access to these services.
Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank Alabama Department of Public Health Chief Medical Officer Mary McIntyre, MD, MPH, SSBB, and Alabama Medicaid Agency Associate Director of Medical Services – Physician and EPSDT Unit, Elizabeth Huckabee for their time and insights. The authors also wish to thank Trish Riley and Jill Rosenthal for their contributions to this blog. Any errors or omissions are the authors’. This project is supported by the CDC.