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States Race to Create COVID-19 Vaccination Distribution Plans

As development of a COVID-19 vaccine continues, states are racing to develop vaccine distribution plans and are eager to ensure that the administrative challenges of testing and personal protective equipment distribution are not repeated. They must orchestrate vaccine storage and administration, data tracking, and capacity issues while questions about who will ultimately pay for the massive vaccine deployment, how it will be equitably distributed, and effective vaccine messaging require a uniform federal response for best results.

Last month, the US Centers for Disease Control and Prevention (CDC) released the COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations. Its publication launched a 30-day deadline for states to create and submit their plans for vaccine-ordering, storage, and handling to the CDC by Oct. 16, 2020. The playbook, which acknowledged there are many unknowns and unanswered questions, will be continually updated by the CDC as guidance and best practices are refined. Recently, the National Academy for State Health Policy (NASHP) convened a cross-sector group of state officials to discuss their distribution strategies. The questions they raised are explored below.

How will the costs of preparation and planning for vaccine distribution be funded?

With CARES Act funding, the Department of Health and Human Services is distributing $200 million across 64 jurisdictions through the existing Vaccines for Children Program (VFC) for vaccine preparedness and planning. The funds are targeted to ensure jurisdictions can develop and update plans for their eventual vaccine distribution. These funds are used to ensure states’ Immunization Information Systems (IIS) are ready to accept all vaccine information, and that providers are enrolled and connected to the system to input their information, among other planning tasks. However, the CARES Act funding allocation uses a population-based formula and is not intended for other expenses related to vaccine administration, such as PPE, and must be spent by the end of 2020. With states already facing limited capacity given current budget constraints, these spending restrictions are expected to further strain state budgets, which could negatively impact their ability to distribute the vaccine to their most vulnerable populations.

There is currently no unified federal plan for distribution of a COVID-19 vaccine, leaving questions unanswered and states in the lead.

States will need to plan to store, administer, and track the COVID-19 vaccines, all while addressing vaccine hesitancies, ensuring equitable distribution, and addressing budget crises caused by the pandemic.

“We need… clarity [from the federal government] around financing early on, especially now that states are beginning to see the budget projections… People will take a more measured approached, and it would be helpful for plans to have a better idea of financing early on so they can plan and get ahead of the vaccine distribution and approval.”

– State Medicaid Official

State leaders also raised concerns about a variety of challenges they face in distributing the COVID-19 vaccine, such as a lack of clarity on federal funding for vaccine administration, refrigeration and storage, and availability of state funding.

According to the CDC playbook, the federal government will procure and distribute the vaccine and any associated supplies (including needles, syringes, and limited masks and face shields) at no cost to providers. Typically, insurance reimbursement to providers includes the cost of the vaccine itself and some of the associated administrative cost. The National Academies of Sciences, Engineering, and Medicine (NASEM) recommended in its framework for equitable vaccine allocation that vaccines be made available at no cost and that administration of the vaccine be adequately reimbursed. However, it is unclear how administrative expenses will be covered and by whom.

Other complications to state planning efforts include:

What and how many vaccines will be rolled out, and over what time periods; and
What refrigeration temperature requirements will be.

For example, given the storage and temperature requirements of one COVID-19 vaccine currently in clinical trial, states are concerned about additional costs of storing, freezing, delivering, and administering vaccines. CDC, meanwhile, has instructed states not to invest in ulta-cold freezers yet.

Vaccine administration can also be prohibitively expensive for facilities. Because there are still so many unknowns about which vaccines will be available and how they will be transported, details about who will ultimately finance these costs are still being finalized. State officials expressed concern that as they face budget crises and limited federal information and regulations, they are being set up to fail.

Who will be the first to be vaccinated?

The CDC recommends that states establish COVID-19 vaccination program implementation committees with representatives from every sector and from communities. The NASEM framework highlights the need for equal regard, maximization of benefits, evidence-based actions, and transparency in decision-making. NASEM and the Advisory Committee on Immunization Practices (ACIP) have been discussing how to prioritize the distribution of the COVID-19 vaccine to critical populations, but delayed making a final decision until a vaccine has been approved by the US Food and Drug Administration for clinical use.

Source: CDC COVID-19 vaccine implementation presentation, July 29, 2020.

The CDC playbook highlights a phased approach to distributing the vaccine and delineates three phases of distribution. However, during Phase 1, which has a limited supply of COVID-19 vaccine doses available, states are encouraged, but not required, to focus their initial efforts on reaching critical populations, including:

Health care personnel who are likely to be exposed while treating people with COVID-19;
Those at increased risk for severe illness, including those with underlying medical conditions and people age 65 years and older; and
Other essential workers.

These phases align closely but differ slightly from NASEM’s equitable distribution framework for Phase 1.

Most state officials noted they intend to follow this guidance for prioritizing an equitable vaccine distribution. But, some states also noted concerns regarding using their immunization systems to identify and distribute the vaccine to these populations, especially to those who live in large, sparse, rural, and frontier areas with smaller public health administrative capacity. Others raised concerns about whether individual providers will be able and willing to administer the vaccine, and if they can do so in a way that follows the equitable allocation framework. Their concerns are tied to cost and reimbursement levels, as well as physical capacity to store and refrigerate the vaccines. Additional federal guidance and funds could alleviate these issues.

Who will pay for the vaccine and associated costs?

The NASEM framework recommends that the COVID-19 vaccine be provided and administered with no out-of-pocket costs. Paul Mango, HHS deputy chief of staff for policy, said the agency’s goal is for the COVID-19 vaccine to be free for all Americans. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, similarly noted, “… The vaccine itself has already been bought by the federal government… A person who gets a vaccine will not pay for the vaccine.” However, Fauci did note that patients could be charged for costs related to the vaccine’s administration. Confusion remains about how these decisions will be made and it remains unclear how administrative expenses will be covered and by whom. For example, in the VFC Program, a provider who administers a qualified pediatric vaccine to an eligible child may not impose a charge for the cost of the vaccine, but can charge a fee for its administration as long as the fee does not exceed the costs of the administration.

ACIP has not yet issued a recommendation on state coverage of a COVID-19 vaccine, but Section 2713 of the Public Health Service Act requires mandatory coverage of all ACIP- recommended vaccines for state Medicaid expansion programs and most commercial health plans (state-based exchanges). ACIP-recommended vaccines are considered preventive and therefore are not subject to cost-sharing by patients. In March, Congress added a COVID-19 vaccine to the list of vaccines commercial health plans are required to cover. Usually insurers have up to a year after a vaccine is recommended by ACIP to implement coverage, but the CARES Act drastically speeds up this timeline by requiring plans to cover a COVID-19 vaccine within 15 days of its approval. The Coronavirus Preparedness and Response Supplemental Act specified that a vaccine should be priced “fairly and reasonably.” And, US officials noted over the summer that they expect insurance companies will not charge copays for COVID-19 vaccinations.

The cost of the vaccine for Medicaid enrollees is expected to vary by state. While Medicaid expansion states require complete coverage of ACIP-recommended vaccines without cost sharing, vaccine coverage is optional in non-Medicaid expansion states and remains up to the state’s discretion. However, through the Families First Coronavirus Response Act, all states are eligible for a temporary (through the end of the public health emergency) 6.2 percent increase to their Federal Medical Assistance Percentage (FMAP). One condition for states to receive this money is that the state plans must cover, without cost sharing, COVID-19 vaccinations.

For Medicare enrollees, vaccines are typically covered under Medicare Part D, which allows for cost sharing. The Centers for Medicare & Medicaid Services (CMS) can opt to cover the COVID-19 vaccine under Medicare Part B (which already covers the influenza vaccine and the pneumococcal pneumonia vaccine), a move that would prohibit cost sharing. As of mid-September, officials were still working with Medicare to figure out the cost to beneficiaries, but noted that the cost would likely not exceed $3.50 out of pocket per individual.

How will states monitor vaccine distribution?

The CDC is developing a Vaccine Administration Management System (VAMS) to manage vaccine administration and provide real-time data from mass-vaccination clinics to federal agencies and state public health departments. The system, funded by an almost $16 million sole-source contract, is designed to share data with existing Immunization Information Systems or immunization registries used by states and territories to record vaccine administration, order vaccinations, and send out vaccination reminders to patients. As of Oct. 7, 2020, however, VAMS has not yet announced plans, leaving state leaders confused about how to plan for vaccine tracking. Concerns have been raised that VAMS might bypass state systems, leaving states unsure whether they will need to use the new system or be able to enhance their existing immunization registry systems in time.

Immunization registries – either VAMS, IIS or a combination of both – will be needed to record vaccination information, identify individuals in need of a first or second dose of a vaccine, remind individuals to get vaccinated, and track follow-up. One critical concern is whether immunization registries have the capacity to ensure that people receive a second dose of the vaccine within an acceptable timeframe and that they receive the same type of vaccine for both doses.

Historical underinvestment in IIS has resulted in wide variation across states’ IIS policies, size, and scope. They have different patient consent policies, reporting mandates, and data-sharing policies. In some states, provider participation in the IIS is mandated by law, and in other states participation is voluntary. As a result, only 55 percent of immunization programs have 95 percent or more of individuals in their jurisdictions registered in their IIS. There is also inconsistent communication between systems. Many electronic health record (EHR) systems are not connected to immunization registries, leaving individuals who receive vaccines at different locations with incomplete immunization records. Although some states receive matching funds available through the Health Information Technology for Economic and Clinical Health Act (HITECH) to enhance interoperability of electronic data exchange between EHR and immunization registries, many rely on the CDC, private foundations, and health care providers and insurers to fund their systems.

Because multiple COVID-19 vaccine doses are forecast to be required, strong data-sharing capabilities between registries also is critical. State IIS need to be able to talk to other health records systems and other states’ immunization registries in order to ensure that individuals receive the correct second dose at a different facility, and even in a different state if necessary. However, in 2018, only 10 percent of immunization registries had conducted at least one query of an IIS in another jurisdiction. While the need for better systems to distribute and monitor the COVID-19 vaccine is clear, because VAMS has not yet released plans, states are left to figure out whether and how to:

Upgrade existing systems, which requires time and resources;
Rely on a new system that will be unfamiliar to providers and clinics; or
Use a combination of both.

How are states promoting public trust in the vaccine?

Vaccine hesitancy will also be a critical issue. According to a recent Pew Study, the number of adults who say they will get a COVID-19 vaccine has fallen from 72 percent in May 2020 to 51 percent in September. Another study found that 35 percent of Americans would not get a vaccine, even if it were free. Mistrust of health care is especially prevalent among Black communities, who are skeptical of the medical system because of current and past discrimination against people of color. This distrust continues as Black Americans are hit hardest by COVID-19, making it even more critical that the government finds ways to boost confidence in COVID-19 vaccine safety.

The need for standardized public health messaging during this pandemic is also clear. In fact, state officials noted that currently, clear and consistent vaccination messaging is one of the biggest issues that states need the federal government to address. Typically, states use a variety of mechanisms for disseminating vaccine information, such as partnering with community organizations, hospitals, and other state agencies to disseminate information to their constituents, sending out clinician letters to providers and pharmacists, and using IIS to send vaccine reminders to patients. These strategies will continue to be important when states market the importance of getting the COVID-19 vaccination.

At the same time that state officials are concerned about gaining and developing public trust in the vaccine, they also need to manage expectations about vaccine availability and efficacy. As noted, the CDC playbook asks jurisdictions to plan for three phases of distribution:

During Phase 1, critical populations such as essential workers and high-risk individuals are prioritized;
In Phase 2, limited doses will be available to the public; and
In Phase 3, there will be sufficient vaccine supply for the entire population.

Public health officials are tasked with instilling confidence in the COVID-19 vaccine and conveying the importance of getting vaccinated to the general public, while simultaneously making it clear that most individuals will not be able to get vaccinated until Phase 2 or 3, which is anticipated to start in fall of 2021. Until that point, and even after, individuals may still need to take other effective measures to present the spread of COVID-19, including social distancing and wearing masks.

State leaders are already concerned about this shift in messaging between phases, and worried about overpromising outcomes without increasing anxiety about the vaccine’s efficacy. In order to help manage expectations about when the vaccine may be available to the public while also combatting vaccine hesitancy, consistent messaging across federal and state agencies is urgently needed.

What partnerships are needed at the state and local levels to ensure seamless vaccine distribution?

As highlighted in the CDC playbook, the pandemic vaccination response requires collaboration among many public and private stakeholders to create and implement plans. State officials at the NASHP meeting noted the complexity involved in rapidly developing plans across agencies and across the public and private sectors.

Officials also raised the issue of involving pharmacists as vaccinators, and onboarding them into IIS. While all 50 states do currently allow pharmacists to vaccinate adults, and recent federal action gives state-licensed pharmacists authority to provide the COVID-19 vaccine to persons age 3 and older, only some states have pharmacists enrolled in Medicaid and the VFC program, with some pharmacists citing difficulty in being reimbursed during previous public health emergencies. Some state officials raised concerns that using pharmacies as immunization access points for COVID-19 could disrupt care in medical homes, particularly for children (although children will not be included in the first round of COVID-19 vaccines.) While the playbook highlights the need for increased access to the vaccine to ensure equitable distribution, states are considering how to balance widespread access to the vaccine with maintaining the importance of medical relationships within existing networks.

What federal leadership is needed?

Despite guidance provided by the CDC, there is currently no unified federal plan for distribution of a COVID-19 vaccine, leaving questions unanswered and states in the lead. States need to plan to pay for, store, administer, and track the COVID-19 vaccines, all while addressing vaccine hesitancies, ensuring equitable distribution, and addressing budget crises caused by the pandemic. State officials predicted that logistical issues will be worked out, but the messaging and finances require a uniform federal response for best results. NASHP will continue to track state and federal preparation for COVID-19 vaccination distribution and engage states in identifying challenges and developing appropriate policy and programmatic responses.

CDC-recommended representatives on state COVID-19 vaccine implementation committees:

• Emergency management agencies

•Health care and immunization coalitions

• Local health departments

• Health systems and hospitals (including critical access hospitals for rural areas, in-patient psychiatric facilities)

• Community and rural Health Clinics (RHCs)

• Pharmacies

• Long-term care facilities

• Businesses and occupational health organizations

• Health insurance issuers and plans

• Education agencies and providers

• Correctional facilities

• Churches or religious leaders and institutions

• Tribal leaders

• Organizations serving racial and ethnic minority groups

• Organizations serving people with disabilities

• Organizations serving people with limited English proficiency

• Community representatives

• Entities involved in COVID-19 testing center organization

“The biggest way to avoid the testing mess… [is] national leadership. [Testing] was such a mess because states were competing with each other… to get supplies.”

– State health official

Results of a Five-State Community of Practice to Improve Medicaid Immunization Rates through Partnerships

October 5, 2020/in Policy Blogs, Featured News Home CHIP, CHIP, Chronic Disease Prevention and Management, Health Coverage and Access, Health Equity, Immunization, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by Rebecca Cooper, Jill Rosenthal and Ariella Levisohn

Faced with persistent disparities in vaccination rates among children and pregnant women, a five-state community of practice, coordinated by the National Academy for State Health Policy (NASHP), AcademyHealth and Immunize Colorado, formed interdisciplinary, cross-agency teams to address access and other challenges to reduce immunization gaps among low-income pregnant women and children. Their approaches and lessons learned can help states address current immunization disparities and be used when a COVID-19 vaccine is available.

Vaccines are a powerful and cost-effective tool to prevent diseases and save lives. According to research estimates, of 4.3 million infants born in 2009 in the United States, vaccines will prevent 40,000 deaths and 20 million illnesses over their lifetimes. Vaccinating children is also cost effective, saving $10.20 for every $1 invested in immunizations. In recognition of these benefits, states continue working to improve immunization rates and use multiple levers, including Medicaid programs, to promote full immunization coverage.

While the Vaccine for Children and Medicaid programs have reduced racial and ethnic disparities for women and children, disparities persist, especially in adult populations. According to a Centers for Disease Control and Prevention (CDC) report published in the Morbidity and Mortality Weekly Report, pregnant women enrolled in Medicaid are less likely to be vaccinated for the flu and diphtheria and pertussis (Tdap) compared to those with private insurance. Common barriers to reaching full immunization coverage include:

Access challenges, including geographic barriers and disparities in health insurance coverage;
Data challenges, including policy, legal, and technical limitations to integrating data between immunization information systems (IIS) and Medicaid information systems (MMIS); and
Policy challenges, including vaccine opt-out policies and optional participation in IIS.

To address these challenges and reduce immunization gaps among low-income pregnant women and children, NASHP, AcademyHealth, and Immunize Colorado coordinated efforts through a three-year CDC cooperative agreement to support states in implementing improvement strategies and policies. The project team convened a community of practice comprised of staff from Medicaid agencies, immunization programs, and IIS, in Colorado, Hawaii, Kentucky, Montana, and New Mexico. These interdisciplinary cross-agency teams worked together towards a shared public health goal of increasing immunization rates. A steering committee of state Medicaid and public health leaders, immunization-focused national organizations, and subject matter experts also provided expertise and guided efforts.

NASHP, AcademyHealth, and Immunize Colorado provided technical assistance in several key areas, including resources around IIS funding and sustainability, cross-agency collaboration, data infrastructure including IIS onboarding support, and provider and community outreach. Over the course of the project, the five states made improvements in those areas of work and developed fact sheets highlighting their successes. For example:

Hawaii and New Mexico strengthened their IIS infrastructure by applying for and receiving a 90 percent match rate through federal Health Information Technology (HITECH) administrative funding.
Kentucky and Montana onboarded new providers (e.g., pharmacists and non-pediatric immunizing health care practices) to their IIS to encourage vaccination of children and pregnant women.
Colorado, Hawaii, Kentucky, and New Mexico improved data-sharing and data analysis capabilities, creating documented memorandum of understanding (MOUs), data dashboards, and data matching between IIS and Medicaid data systems.
Two states enacted legislation to increase access to vaccinations: Hawaii required students entering seventh grade to receive the human papillomavirus (HPV), TDap and meningococcal vaccines (which affect more than 13,000 children per year), and Montana lowered the minimum age for which pharmacists may vaccinate children.
States also added immunization measures to state Medicaid value-based programs to capture and reward quality improvement.

Changes in State Medicaid and Children’s Health Insurance Program Measures and Incentives for Childhood and Adolescent Immunizations
State	2015 Measures and Incentives for Immunizations	2020 Measures and Incentives for Immunizations	Change?
Colorado	Managed Care Organization Performance Improvement Project (MCO PIP)	MCO tracking measure MCO performance measure	Yes
Hawaii	Medicaid performance measure	Medicaid performance measure
Kentucky	MCO-required Healthcare Effectiveness Data and Information Set (HEDIS) reporting measure	MCO-required HEDIS reporting measure
Montana	N/A	Patient-centered medical home (PCMH) measure Medicaid performance measure	Yes
New Mexico	MCO PIP	MCO tracking measure MCO performance measure	Yes

Data from NASHP’s State Strategies to Promote Children’s Preventive Services. Chart updated March 2020.

States worked towards their project goals of improving immunization rates for pregnant women and children by creating and strengthening partnerships between Medicaid and public health agencies. Stronger Medicaid and public health partnerships enable states to identify disparities and target additional outreach and interventions.

These state partnerships and system improvements ensure a foundation for future immunization efforts. States will be able to use this strong foundation for more efficient vaccine distribution, data tracking and reporting, communication, and provider outreach and engagement, and, these frameworks will be critical in a future dissemination of a COVID-19 vaccine.

As these states continue to implement their immunization strategies and navigate this new health landscape with the added challenge of COVID-19, NASHP, Academy Health, and Immunize Colorado will engage additional states in efforts to improve immunization systems through cross-agency collaboration, using the lessons from these five states to address disparities in immunization rates among children and pregnant women.

States Include Catch-up Routine Immunization Strategies in Back-to-School Planning

July 27, 2020/in Policy Hawaii, Michigan, Oregon, Texas Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Immunization, Maternal, Child, and Adolescent Health, Population Health /by Rebecca Cooper

As states consider strategies to reopen schools safely this fall, ensuring that children receive their appropriate, on-schedule vaccines continues to be an important safety and prevention strategy. Because the COVID-19 pandemic has dramatically reduced the volume of in-person children’s preventive care visits across the country – many providers have reported a 70 to 80 percent decrease in well-child visits with fewer children receiving immunizations – catching children up on missed routine immunizations is critical, regardless of whether schools offer in-person instruction.

The American Academy of Pediatrics states that, “existing school immunization requirements should be maintained and not deferred because of the current pandemic,” and according to a 2014 study, vaccines will prevent 40,000 deaths and 20 million illnesses over the lifetimes of US children born in 2009. As a result, many school districts are implementing strategies that include immunizations along with other health priorities, like social distancing, mask wearing, and increased hygiene measures, for students in their back-to-school plans.

The Centers for Disease Control and Prevention’s (CDC) priorities for the fall include catching children up on needed routine vaccinations and ensuring that adults and children get their annual flu shots to stay healthy and reduce the risk of coinfections and the burden on the health care system. CDC also recently released guidance to assist local public health agencies in establishing satellite vaccination clinics for routine vaccinations, including back-to-school immunizations and annual flu shots. Considering the immense pressures teachers and school administrators face as policymakers grapple with school reopening decisions, continuing to provide protection from preventable diseases is critical.

Keeping children protected from vaccine-preventable diseases is not contingent on in-person learning. States need to continue to plan for catch-up vaccinations even if states and school districts have not yet solidified their reopening plans amid rising national COVID-19 case counts, and children should have all necessary protections from vaccine-preventable diseases. However, because some states are requiring all schools to open, it is especially important to ensure there is a process for appropriate back-to-school vaccinations to be administered to keep children healthy. Several states and counties have already released back-to-school immunization plans:

Hawaii: Effective July 1, 2020, additional immunizations will be required for students entering childcare facilities or schools. By the first day of school, all students entering childcare or school in Hawaii must have either a completed health record form or an appointment already scheduled with a health care provider, as well as a completed tuberculosis (TB) clearance form. Students who have not completed the requirements will not be allowed to attend school until the requirements are met. The updated immunization requirements were enacted prior to the pandemic to conform with national recommendations and reflect what already existed as standard medical care in Hawaii. State officials chose to maintain this guidance despite uncertainty from COVID-19.
Michigan: Its Department of Health and Human Services (DHHS) is urging families to catch their children up on needed vaccines that were postponed during the COVID-19 pandemic. Michigan providers are implementing new procedures to ensure patients can come in for well-child visits and get caught up on immunizations, including the flu vaccine, in the fall. Additionally, bipartisan legislation was introduced that requires proof of vaccination before entering 12th grade to ensure an accurate immunization status for high school students, and directs the DHHS to adopt the CDC-recommended immunization schedule.
Texas: The state announced that school vaccination rules are in effect for the 2020-2021 school year that students should be up-to-date, or in the process of receiving their vaccinations, or have a valid exemption when school starts. Texas’ school vaccination rules are in effect regardless of where the education is received (on campus or via virtual learning).
Oregon County: Oregon county health Departments began scheduling 2020-2021 school year catch-up immunizations during the summer to help limit the number of individuals in provider offices receiving vaccines at any one time, and to help prevent running out of supplies, because the department is only able to place new vaccine orders once a month.

In the midst of an uncertain infectious disease climate, states continue to prioritize maintaining immunization rates, and states can use back-to-school immunization requirements as a tool to ensure timely vaccine catch-up. However, vaccine requirements are a contentious issue and state legislatures across the nation continue to debate this topic. Prior to the start of the COVID-19 pandemic, Colorado and Maine, for example, enacted new school entry immunization laws that created more stringent procedures for obtaining immunization exemptions. These states are working to prevent future outbreaks, considering the evidence that unvaccinated populations can lead to community outbreaks.

States will also need to consider strategies to ensure school-aged children will have equitable access to the COVID-19 vaccine when it becomes available. In Wisconsin, for example, both the state legislature and the Department of Health Services can add new vaccines, such as a potential new COVID-19 vaccine, to Wisconsin’s list of required vaccines for school children and children in childcare settings. Other states are taking preventive action to ensure they have a system in place for vaccine distribution when it is available. For example, New York amended a law authorizing licensed pharmacists to administer any approved vaccine for COVID-19 to include children between the ages of 2 and 18.

Schools are often under local jurisdictions and while considering federal guidance and local public health risk, most decisions will be made at the state and local levels. But, regardless of the variation, states have to make challenging decisions about reopening schools in the midst of the COVID-19 pandemic. One critical step they can take to ensure student’s health is prioritizing immunizations to ensure children are protected from preventable disease regardless of whether schools reopen in-person. The National Academy for State Health Policy will continue to monitor state back-to-school immunization policies, state efforts to keep children protected from vaccine-preventable diseases, and their implications for children.

This blog was written with support from the Centers for Disease Control and Prevention.

State Immunization Services and Policies Resource Page

June 23, 2020/in Policy Toolkits Chronic Disease Prevention and Management, Healthy Child Development, Immunization, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health Immunization /by Rebecca Cooper

Despite the availability of safe and effective vaccines through Medicaid and the Vaccines for Children program, immunization rates among children enrolled in Medicaid remain lower than for privately-insured children. Disparities in vaccination rates also persist for African-American children and those living in poverty. Nearly half of US pregnant women are covered by Medicaid, but data shows that publicly-insured women have lower immunizations rates than women with private insurance.

These resources showcase effective state efforts to harness Medicaid’s reach to increase immunization rates in these important populations. To suggest a resource or share your state’s immunization efforts, contact Ariella Levisohn.

Resources

States Factor in COVID-19’s Impact on Immunizations and VBP Incentives, June 2020. In recent years, a number of state Medicaid programs have instituted value-based payment (VBP) programs to reward managed care organizations for quality care, including achieving high child immunization rates. However, COVID-19 has reduced in-person visits and immunization rates, and this blog examines federal and state guidance and flexibility in VBP incentive calculations to accommodate these declines.

States Establish New Telehealth Policies to Safeguard Well-Child Care and Immunizations, May 2020. COVID-19 has affected children’s access to preventive care across the country; while states’ expanded telehealth policies can increase access to care, in-person visits are still needed for delivery of immunizations and other critical screenings. This blog highlights new state policies on telehealth and well-child visits to ensure children stay healthy during this pandemic and beyond.

State Levers to Improve Immunization Rates: Alabama’s Experience, February 2020. Alabama employs a multifaceted approach to boost immunization rates among its Medicaid, public, and privately covered populations. This NASHP blog details the state’s strategies, including various payment and reimbursement incentives, reporting protocols, and cross-agency partnerships.

Using Data and Innovation, States Work to Improve Maternal Vaccination Rates, November 2019. This NASHP blog examines different strategies California, Colorado, and Wisconsin are using to improve maternal vaccination rates, ranging from including requirements and incentives in Medicaid managed care contracts to using data to identify populations, regions, and providers with low immunization rates.

State Medicaid Levers to Promote Immunization: California’s Experience, September 2019. This NASHP blog highlights strategies California is using to increase childhood immunization rates among Medicaid enrollees, including incentivizing providers, using the state immunization registry to monitor vaccination uptake and requiring managed care organizations to monitor and report on quality measures.

Hawaii Fights the Flu with Pop-up Clinics and State Agency Collaboration, February 2019. This NASHP blog highlights Hawaii’s collaboration between its state education and health departments, which led to “pop-up,” school-based vaccination clinics to increase flu vaccination rates and protect children’s health.

How to Boost Vaccine Rates for Low-Income Families, October 2018. This PEW Charitable Trusts article explores a Community of Practice Immunization project, co-led by the National Academy for State Health Policy, AcademyHealth, and the Colorado Children’s Immunization Project.

State Officials Work to Harness Medicaid as a Change Agent to Increase Immunization Rates, July 2018. This reports on a meeting led by NASHP, AcademyHealth, and the Colorado Children’s Immunization Coalition, which convened state officials and experts to identify strategies to improve immunization rates among Medicaid-enrolled children and pregnant women.

Immunization Community of Practice, February 2018. AcademyHealth and NASHP, with support from the Colorado Children’s Immunization Coalition, worked with state officials interested in improving their immunization rates among low-income children and pregnant women in a Community of Practice. Medicaid agencies worked with public health and Immunization Information System partners to improve policies and outreach to increase immunization rates.

New Program Helps State Medicaid Programs Close an Immunization Disparity Gap, February 2018. This NASHP blog explores how states can improve immunization rates among low-income children by addressing health equity.

State Immunization Strategies to Promote Children’s Preventive Services, last updated September 2016. These maps and 50-state chart illustrate state Medicaid or Children’s Health Insurance Program performance-improvement initiatives that promote children’s preventive services, including immunizations and American Academy of Pediatrics’ Bright Futures recommendations.

Vaccination Coverage Among Children Aged 19–35 Months — United States, 2017, October 2018. This Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Review (MMWR) article highlights current vaccination coverage data and trends.

Vaccine-Preventable Diseases, Immunizations, and MMWR –1961 – 2011, October 2011. This CDC report discusses the history of vaccine-preventable diseases, current global efforts, and the future of immunizations.

States Establish New Telehealth Policies to Safeguard Well-Child Care and Immunizations

May 11, 2020/in COVID-19 Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, EPSDT, Health Coverage and Access, Health IT/Data, Healthy Child Development, Immunization, Lead Screening and Treatment, Maternal, Child, and Adolescent Health, Population Health, Workforce Capacity /by Rebecca Cooper

The COVID-19 pandemic has reduced access to children’s preventive care across the country, with some providers reporting a 70 to 80 percent decrease in well-child visits, and far fewer children receiving vital in-person services, such as immunizations. Some primary care practices also have limited their services or shut down to comply with mandatory social distancing policies. To ensure children and families are able to stay safe and receive appropriate care, states are providing new guidance for telehealth visits.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT), the required Medicaid benefit for comprehensive and preventive health care services for children and youth up to age 21, includes well-child visits and immunizations. Well-child visits are necessary to prevent disease, administer scheduled immunizations, track healthy growth and development, identify health concerns early when they are easier and less costly to treat, and address parental and caregiver concerns.

In addition to a drop in well-child visits because of the pandemic, the US Centers for Disease Control and Prevention (CDC) released data showing that provider requests for childhood immunizations began dropping within a week of the national emergency declaration, signaling an immediate decline in routine immunizations for children. Several states, including California, Indiana, Kentucky, New Hampshire, North Carolina, South Carolina, Tennessee, and Washington State, have issued specific bulletins with information on EPSDT/well-child visits, including clarification of what services can be delivered via telehealth and billing guidance, so that these services can be provided during the pandemic to maintain healthy child development.

The Centers for Medicare & Medicaid Services (CMS) has also provided states with overarching telehealth guidance to promote access to care. Through executive orders and legislative authority, many states are ensuring telehealth services are easily accessible and that patients are not deterred from seeking necessary care during the pandemic that they would otherwise be unable to receive in person. States are also working to ensure that telehealth policies do not exacerbate existing disparities in care. Some examples of general state telehealth policy changes include:

Arkansas and Missouri recently relaxed the requirement that telehealth visits must only be conducted with previously established patients.
Arizona mandated that cost sharing for telehealth visits should be lower than in-person visits.
Oregon stipulated that cost sharing for telehealth services should not be greater than that for in-person visits.

While expanded telehealth policies increase access to primary care virtually during the pandemic, limiting in-person visits can reduce children’s ability to receive timely immunizations . Childhood immunizations are a cost-effective way to prevent disease, and vaccines are one of the most important public health tools to ensure health in a community, however, overall immunization rates are decreasing during the pandemic. The American Academy for Pediatrics (AAP) guidance encourages providers to prioritize in-person newborn care and well-child visits and immunizations for infants and children up to 24 months, and new CDC data shows a less prominent decline in immunizations for children under 24 months compared to children over 24 months. To address these immunization lags and promote access to other important preventive care, states have released guidance based on the needs of their own populations and their own provider capacity. For example:

Indiana and Kentucky’s policies for EPSDT visits note that providers need to complete the components of the visit that could not be done via telehealth (e.g., immunizations) in a follow-up visit within six months of the end of the public health emergency.
South Carolina and Tennessee’s guidance notes that when pediatric well care is provided via telehealth, the providers must inform the Medicaid enrollee (or parent/guardian) of any immunizations that would normally be administered and schedule a time to administer the vaccines as soon as possible after the telehealth visit. The providers bill for administering the immunization whenever it is delivered outside of the telehealth visit, such as on a different day, at a separate location, or through a drive-up immunization model.
Several states, including Maine, are encouraging practices to schedule well-child visits and administer immunizations in the morning and sick visits in the afternoon to keep the healthy and sick segregated. Other guidance to maintain well-child visits includes separating patients spatially, by placing patients with sick visits in different areas of the clinic or a different location from patients who are present for well visits.
Washington, DC and North Carolina’s guidance recommends providers utilize telehealth visits wherever possible, and that the subsequent, in-person follow-up visit should be as soon as is safe, based on the provider’s discretion. Washington, DC’s guidance also notes that if possible, pediatric immunizations, vital signs for infants up to 12 months, blood lead level screenings for children under 26 months, and infant anemia screening should not be delayed.

States also choose the billing codes and modifiers to track telehealth well-child visits and the subsequent follow-up visits for immunizations and other in-person services. For example:

Alabama directs providers to use code 02 in the place of service field to indicate telemedicine and use the modifier CR, for a “catastrophic event.”
Washington State providers must use EPSDT codes plus the CR modifier. For in-person follow-up appointments to complete the EPSDT visit, providers should use code 99429 with the CR modifier.
Kentucky providers should use 02 in the place of service field, and no modifiers are needed. For vaccine administration, providers bill code 90460 at the time of vaccine administration.
Alaska providers should use 02 in the place of service field, and modifiers 95, GT, or GQ to indicate a telehealth visit.

Well-child visits are an important vehicle for providers to assess healthy child development. There are many potential long-term implications of the pandemic on these visits, including primary care practices permanently shutting down due to lack of funding. Limited workforce capacity may lead to potential pent-up demand for pediatric preventive services resulting in:

A reduction in immunizations that can lead to an increase in vaccine-preventable diseases;
Less access to blood lead level screenings, which also has implications for children’s health outcomes; and
Reduced identification of adverse childhood experiences and trauma, with less capability to connect children and families to needed treatment and follow-up services.

State Medicaid and public health agencies are working closely to follow guidance from the Department of Health and Human Services (HHS), CMS, and CDC, with guidance from the AAP and American Academy of Family Physicians (AAFP) to ensure well-child visits are as uninterrupted as possible, so children can receive preventive services like immunizations, and subsequent vaccine-preventable outbreaks do not occur.

The National Academy for State Health Policy is continuing to monitor state and federal guidance to support states in ensuring children stay healthy during this pandemic and beyond.

This blog is supported by the David and Lucille Packard Foundation and the Centers for Disease Control and Prevention (CDC). To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.

Using Data, Incentives, and Innovation, Three States Work to Improve Maternal Vaccination Rates

November 4, 2019/in Policy California, Colorado, Wisconsin Blogs, Featured News Home Chronic Disease Prevention and Management, Health Coverage and Access, Health IT/Data, Immunization, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Social Determinants of Health /by Ariella Levisohn

Despite the health benefits of immunizing pregnant women against influenza and pertussis (whooping cough) and protecting them and their infants from these life-threatening diseases, only half of pregnant women are vaccinated against both diseases and only one-third receive both the influenza and pertussis vaccines during pregnancy.

Three states are trying a number of innovative approaches to increase vaccination rates among pregnant women by providing incentives to health plans, increasing access to vaccinations through pharmacies, and using data to identify and target populations, regions, and providers with substandard influenza and Tdap (which protects against pertussis) vaccination rates.

Evidence shows pregnant women are at increased risk of developing complications from certain preventable diseases and can also risk passing those diseases on to their children. Following immunization, data shows that both mothers and infants are less likely to be hospitalized from complications. When a woman is vaccinated during pregnancy, she develops antibodies that are transmitted to her child before birth, which can then protect the infant during the first few months after birth. The US Centers for Disease Control and Prevention (CDC) recommends that women who are pregnant or planning to become pregnant get the flu vaccine and the Tdap vaccine during each pregnancy.

Low Immunization Rates Persist

Despite the CDC’s guidelines, many women do not receive the influenza and pertussis vaccines during pregnancy. According to the CDC’s recent report, Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants — United States, published in Morbidity and Mortality Weekly Report (MMWR), current rates of maternal immunization for influenza and Tdap are 53.7 percent and 54.9 percent, respectively. Only one-third of pregnant women received both the influenza and Tdap vaccines, and the rates are even lower for African-American pregnant women. The report noted that provider recommendations to patients can improve maternal immunization rates – when providers offered vaccinations or provided a referral to pregnant women, 65.7 and 70.5 percent received the flu and Tdap vaccine, respectively. Based on this data, the CDC recommends that providers begin discussing vaccinations with pregnant patients early and continue the conversation during each visit.

Overall, women enrolled in public insurance programs were less likely to be vaccinated during pregnancy than women with private insurance, due in part to access barriers. State Medicaid agencies, which cover 43 percent of all births across the United States and up to 60 percent of births in some states, can use innovative approaches to identify pregnant women in need of vaccinations, gather data to identify strategies and targeted approaches, and encourage providers to increase vaccination rates to improve health and save on costs.

The 2019 MMWR data are especially notable in light of the Healthy People 2020 goal to increase the number of pregnant women vaccinated against influenza to 80 percent. While most states remain far from that goal, California, Colorado, and Wisconsin are working to improve maternal vaccination rates for both their Medicaid populations and privately insured women.

California’s Medi-Cal Strategies

In California, pregnant women covered by Medi-Cal, the state’s Medicaid plan, see providers who are less likely to stock or recommend the Tdap vaccine. Women on Medi-Cal receive prenatal Tdap immunizations at much lower rates than privately insured women, and infants born to mothers with Medi-Cal coverage are twice as likely to contract pertussis compared to privately insured infants. California is using a number of strategies to improve maternal immunization rates for women on Medi-Cal, including setting expectations for contracted health plans, monitoring and providing incentives, and addressing barriers at the clinician and patient level:

Medi-Cal managed care contracts require health plans to ensure the timely provision of all Advisory Committee on Immunization Practices (ACIP)-recommended immunizations for members, and report data to the California Immunization Registry (CAIR). Medi-Cal managed care contracts also require that contracted health plans monitor their primary care provider sites for the provision of preventive services, including all ACIP-recommended immunizations for adults and children.

California’s 2019-2020 budget includes funding for incentive payments in the managed care delivery system for timely prenatal care as well as for prenatal providers who administer the Tdap vaccine to pregnant members. Some of California’s Medi-Cal managed care health plans are also trying to lower the financial barriers to providing vaccines by allowing providers to directly bill the health plan outside of capitation rates, providing free Tdap starter doses to clinics, and encouraging group purchasing of vaccines.

Medi-Cal encourages its health plans to follow up on potential quality of care issues when cases of pertussis in infants born to unvaccinated mothers are identified through public health department notification.

California pharmacists are authorized to provide immunizations without a physician’s order. Most major chain pharmacies in California offer Tdap immunizations as part of their vaccine portfolio. All routinely recommended adult vaccines are covered by Medicaid without prior authorization (in both fee-for-service and managed care plans) when given in a provider’s office or in a pharmacy. Recent state regulations require pharmacists to notify providers of immunizations administered and to enter all doses into the California Immunization Registry, making it possible for providers to know whether vaccine referrals to pharmacies are successful.

Colorado and Wisconsin’s Use of Data

One of the challenges to improving maternal immunization rates is obtaining and monitoring data, especially as many states do not require providers to report immunizations to their Immunization Information Systems (IIS). Quality data, though, is needed by states working to tailor their strategies for improving immunization uptake to the areas of highest need and to monitor trends. Specifically, the Centers for Medicare & Medicaid Services identifies data linking of Medicaid eligibity and claims data with vital statistics data as a critical mechanism for surveillance, programmatic monitoring, and evaluation of maternal immunization.

Colorado is using data matching to determine the rates of maternal immunization in each county. Colorado has successfully matched 96 percent of patient medical record numbers with Colorado Immunization Information System (CIIS) records. The CIIS data matching has allowed the state to map immunization rates by provider and region and identify gaps in maternal immunization uptake. Colorado is now using this data to determine the areas of highest need in the state to inform and guide outreach programs. Currently, Colorado is also piloting text and email reminders to encourage patients to get vaccinated.

Wisconsin is also using data matching to obtain baseline immunization rates. Wisconsin matched 96 percent of women who gave birth in 2018, as recorded by the Vital Records Office, with data from the Wisconsin Immunization Registry. Like Colorado, Wisconsin used this data to create data maps to identify influenza and Tdap vaccination levels in each region of the state. Wisconsin was also able to track vaccination rates by age, race, type of insurance, and quality of prenatal care. Next steps for the state include monitoring these trends, identifying areas of highest need, and using the data to improve maternal immunization rates.

In addition to partnering with state public health departments and their immunization programs, state Medicaid agencies can partner with providers to ensure vaccines are stocked and to promote vaccine recommendations for pregnant women so they become routine. For example, the American College of Obstetricians and Gynecologists has released a number of resources designed to support health care providers in increasing maternal vaccination rates, including the Maternal Immunization Tool Kit, strategies for immunization implementation, and a guide to starting an office-based immunization program. The American Academy of Pediatrics also offers recommendations on cost-saving measures for the purchase and administration of immunizations. Finally, the CDC has compiled a toolkit for prenatal care providers that includes resources for provider and patient vaccination education.

In addition to these resources, other states can learn from the work California, Colorado, and Wisconsin have done to identify gaps and improve vaccination rates among pregnant women covered by state Medicaid programs.

Acknowledgements:
The National Academy for State Health Policy (NASHP) would like to thank Abby Klemp at the Wisconsin Department of Health Services, Sarah Royce at the California Department of Public Health, and Karen Mark at the California Department of Health Care Services for their time and insight. NASHP would also like to thank the US Centers for Disease Control and Prevention for their assistance with this blog and for funding this project.

State Medicaid Levers to Promote Immunization: California’s Experience

September 9, 2019/in Policy California Reports CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Eligibility and Enrollment, EPSDT, Essential Health Benefits, Health Coverage and Access, Health Equity, Health IT/Data, Health System Costs, Healthy Child Development, Immunization, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by Rebecca Cooper

Vaccines are a powerful and cost-effective tool to prevent diseases and save lives. Once common, deadly diseases such as polio, measles, and mumps are preventable and smallpox no longer exists outside of a laboratory. According to research estimates, of 4.3 million infants born in the United States in 2009, vaccines will prevent 40,000 deaths and 20 million illnesses over their lifetimes. Vaccinating children is also cost effective, saving $10.20 for every $1 spent on immunizations.

Despite these successes, states are working to improve their immunization rates, which hovered at 68.4 percent nationwide in children ages 19 to 35 months in 2012. California is using an assortment of strategies and inducements to boost its immunization rates.

How Can States Increase Immunization Rates through Medicaid?

Medicaid plays a key role in the delivery of vaccines, especially among vulnerable populations including children and pregnant women. Because Medicaid covers a large percentage of US children (39 percent), increasing childhood immunization rates among Medicaid beneficiaries can generate significant long-term savings. 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, and protected millions from serious diseases.

State Medicaid programs can employ a variety of levers to increase immunization rates among their beneficiaries, from ensuring access and coverage for vaccines to tracking targeted metrics that inform provider incentive payments and reimbursement. These levers include:

Providing comprehensive coverage: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is Medicaid’s benefit for children and adolescents younger than 21, as described in Sec. 1905(r) of the Social Security Act. The EPSDT benefit requires that states provide all vaccines recommended by the Advisory Committee on Immunization Practice (ACIP) to all children eligible for EPSDT benefits.
Making vaccine available: Through the Vaccines for Children (VFC) program, the CDC purchases vaccines at a discount and distributes them to state health departments and other local and territorial public health agencies. These entities distribute the vaccines to private and public health providers who are registered as VFC Children are eligible for VFC-funded vaccines if they are younger than 19 and Medicaid-eligible, uninsured, American Indian or Alaska Native, or underinsured and vaccinated in certain settings. VFC-eligible children receive recommended vaccines at no cost when administered by a registered VFC provider.
Using metrics: The US Department of Health and Human Services sets annual Medicaid and Children’s Health Insurance Program (CHIP) health care quality measures to ensure providers deliver appropriate care to their patients. The 2019 Medicaid and CHIP Core Set of Children’s Health Care Quality Measures includes the Healthcare Effectiveness Data and Information Set (HEDIS) Childhood Immunization Status measure.* Monitoring and measuring changes in vaccine delivery through this metric is a critical step to improving targeted immunization rates.
Using incentive measures: State Medicaid programs can use incentive payments to increase immunization uptake. For example, evidence shows that incentive payments to providers through Medicaid pay for performance programs increases childhood immunization rates.
Performance improvement projects (PIPs): State Medicaid programs can encourage managed care organizations (MCOs) to focus on improving immunization rates by including it as one of their PIPs. Medicaid MCOs participate annually in PIPs.
Form partnerships to strengthen immunization efforts: Multiple state agencies play an important role in increasing immunization rates. Medicaid and public health agencies can partner with other stakeholders to address mutual goals.
Data sharing: States have various data sources from different agencies that may include information on vaccination status. This includes immunization information systems (IIS), which are confidential, population-based computerized registries that record vaccination doses and are usually maintained by public health departments, and Medicaid Management Information Systems (MMIS), which contain Medicaid claims data. Data exchanges between IIS and MMIS can help identify missed opportunities for vaccination, monitor gaps in immunization coverage, and improve vaccination rates.

California’s Strategies

A Healthy People 2020 immunization target is to increase the percentage of children ages 19 to 35 months who receive the recommended doses of diphtheria, tetanus, and pertussis (DTaP), polio, mumps-measles-rubella (MMR), Hib (meningitis), hepatitis B, varicella and pneumococcal conjugate vaccine (PCV) to 80 percent, from the 2012 average of 68.4 percent. As of 2017, California’s combined seven-vaccine series coverage rate among children ages 19 to 35 months was 68.6 percent. California’s health-related agencies have been working over the last several years to increase the state’s childhood immunization rates. Medi-Cal, California’s Medicaid Program, covers 43 percent of children in the state, so Medi-Cal has strong incentives to work to improve vaccination rates among its beneficiaries. Medi-Cal uses the following levers to reach this goal.

Comprehensive coverage: The California Department of Health Care Services (DHCS) administers the EPSDT benefits to all low-income youth enrolled in Medi-Cal consistent with the federally mandated benefit. Pregnant women (of any age) and all children younger than 21 are eligible for Medi-Cal if they meet income limits.
Vaccine availability: Medi-Cal participates in the VFC program to ensure that vaccines are eligible at no charge to public and private providers for eligible children. DHCS reimburses enrolled providers the administrative fee per dose of vaccine. In 2018, the California Department of Public Health (CDPH) distributed approximately $665 million worth of ACIP-recommended pediatric vaccines through the VFC program. Immunizations are also a medical and pharmacy benefit for all adult Medi-Cal members, including pregnant women.
Metrics: California’s Medi-Cal program collects the HEDIS measure “Childhood Immunization Status” from all of its MCOs, which requires the administration of the 10 ACIP-recommended vaccines by age two. MCOs are required to meet a minimum performance benchmark on the childhood immunization measure – 50 percent of all Medicaid health plans nationally, as determined by the National Committee for Quality Assurance). When MCOs do not meet the benchmark, quality improvement work is required, sanctions are imposed, and corrective action may be imposed. MCOs are contractually required to document each member’s need for ACIP-recommended immunizations as part of all regular health visits, and to ensure that all children receive ACIP-recommended immunizations at any health care visit.
Incentive measures: California’s Medi-Cal program operates a directed payment Quality Incentive Program (QIP) that directs MCOs to make QIP payments to designated public hospital systems tied to performance on specific performance metrics, including the Childhood Immunization Status and Immunization for Adolescents measures. As part of California’s 1115 Waiver, Medi-Cal provides incentive payments to designated public hospital and district and municipal hospital systems tied to performance on specific performance metrics, including the Influenza Immunization measure for members ages six months and older [California’s Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program]. In addition, California’s Medi-Cal Value-Based Payment Program provides an incentive payment to providers for administration of several vaccinations, including the pertussis vaccine to women who are pregnant (supporting the HEDIS Prenatal Immunization Status Measure), the influenza vaccine to adults 19 years and older, and the last dose of any of the multiple-dose vaccine series given on or before a child’s second birthday (DTaP, polio, hepatitis B, Hib, pneumoconccal conjugate, rotavirus, and influenza), supporting the Childhood Immunization Status measure.
Performance improvement projects (PIPs): In 2016, DHCS identified improving childhood immunization rates as one focus topic for its PIP because less than three-quarters of young children enrolled in Medi-Cal were fully immunized, and immunization is an area with quantified health disparities, especially within the Medicaid program. Between 2015 and 2017, five health plans participated in PIPs to improve immunizations of two-year-olds. In 2018, health plans with low or declining performance on the HEDIS childhood immunization indicator were required to participate in a childhood immunization-focused PIP. Between 2017 and 2019, 15 health plans participated in PIPs to improve childhood immunization rates. Beginning in the fall of 2019, health plans will embark on their third round of PIPs, one of which will focus on childhood and adolescent health. To date, seven health plans have submitted PIP-focused proposals to improve childhood immunization rates. Separate from the PIPs, as noted above, when health plans do not meet the required performance benchmark for the childhood immunization measure, DHCS requires those plans to conduct a rapid cycle quality improvement project to improve their immunization rates. DHCS is striving to increase its overall managed care childhood immunization rate to at least 80 percent coverage.
Partnerships that strengthen immunization efforts: Medi-Cal partners with multiple stakeholders, including CDPH and other state agencies, health care providers, and other private entities. CDPH provides technical assistance to public and nonprofit health clinics, participates in the multi-sector California Immunization Coalition, and assists schools and childcare centers in complying with state immunization requirements.

CDPH continues to develop and support efforts to address disparities in immunizations of minority and uninsured children, including a focus on increasing prenatal immunization with the TDaP vaccine among pregnant Latina women. In 2015, CDPH undertook several initiatives, including the DHCS National Governor’s Association Learning Collaborative, to increase prenatal immunization rates.

Data sharing: California’s IIS – the California Immunization Registry (CAIR) – supports immunization by:
- Providing a comprehensive immunization record that can adapt to changes in the medical home or health insurance;
- Calculating which shots children need and minimizing under- or over-immunization;
- Issuing reminders of upcoming visits; and
- Identifying individuals and populations with low immunization rates.

The Medi-Cal program requires its MCOs to ensure that immunizations are reported to the registry. California physicians’ offices, clinics, families, and schools are estimated to have saved several millions of dollars annually as a result of the registry.**

California uses strategic levers to increase immunization rates in its Medicaid population, including identifying the target populations’ EPSDT benefits, identifying metrics for quality improvement programs, and developing strategies to incentivize providers to improve their immunization rates. These levers enable the Medicaid agency to contribute as a critical partner to a strong state partnership supporting a comprehensive strategy for improving immunization rates.

* Percentage of children age two who received four diphtheria, tetanus and acellular pertussis (DTaP); three polio; one measles, mumps and rubella (MMR); three haemophilus influenzae type B; three hepatitis B, one chicken pox; four pneumococcal conjugate; one hepatitis A; two or three rotavirus; and two influenza vaccines by their second birthday. This measure calculates a rate for each vaccine and nine separate combination rates.

** California Immunization Registry (CAIR) users include health care providers, public health departments, schools, childcare facilities, family child care homes, WIC service providers, foster care agencies, welfare departments, juvenile justice facilities, and other programs that provide, track, or promote immunization.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank Mary Beth Hance at the Center for Medicare and Medicaid Services, Megan Lindley and Aaron Borrelli at the Centers for Disease Control and Prevention (CDC), Sarah Royce at the California Department of Public Health and Linette Scott at the California Department of Health Care Services for their time and insights, which made this blog possible. The author also wishes to thank Trish Riley and Jill Rosenthal for their contributions to this case study. Any errors or omissions are the author’s. This project is supported by the CDC. This information or content and conclusions are those of the authors.

New Program Helps State Medicaid Programs Close an Immunization Disparity Gap

February 27, 2018/in Policy Blogs CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Healthy Child Development, Immunization, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by Megan Lent

State Medicaid programs play a vital role in protecting public health by ensuring that children receive all of their recommended immunizations. If all children born in 2009 were fully immunized, for example, it would prevent 42,000 early deaths and 20 million cases of disease, while saving the country more than $13.5 billion in direct health care costs and $68.8 billion in total societal costs.
But a vaccination coverage gap remains for low-income children covered by Medicaid. In 2016, immunization rates for children enrolled in state Medicaid programs were 2.5 to 12 percent lower than among privately-insured children.
The United States has made great progress to reduce vaccine-preventable illnesses. Declines in these diseases and their associated health care costs are considered one of the greatest public health achievements of the last decade, and annual cases of many vaccine-preventable illnesses have dropped to historically low levels.
All children who are eligible for the Early and Periodic Screening, Diagnostic and Treatment benefit are covered for all vaccines recommended by the Advisory Committee on Immunization Practice. The Vaccines for Children (VFC) program provides immunizations at no charge to physicians’ offices and public health clinics that are registered as VFC providers.
While immunization rates for most recommended vaccines among children remain high overall, rates are often lower among children living in poverty. African American children also have lower immunization rates than white children. For example, in 2016 only 76.8 percent of African American children received at least four doses of the diphtheria, tetanus, and pertussis vaccine (DTaP) compared to 84.8 percent of white children. According to the US Centers for Disease Control and Prevention (CDC), only 65.5 percent of children living below poverty received the rotavirus vaccine, compared to 78.2 percent of children living at or above poverty.
These disparities point to a missed opportunity to both support children’s health and reduce health care costs.
The National Academy for State Health Policy and AcademyHealth, with support from the Colorado Children’s Immunization Coalition, will be working with states interested in improving Medicaid policies and outreach to increase immunization rates among low-income children and pregnant women. State Medicaid agencies, in partnership with their public health and immunization information system partners, will receive one-on-one consultations, opportunities to learn from other participating states, and annual in-person meetings. This project is funded through a CDC cooperative agreement.
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