4

Accountability and Responsibility for Providing Immunizations

Accountability for ensuring that all children are immunized has been missing but will be essential to reach the 1996 target of 90 percent immunization coverage among preschool children and to achieve and sustain higher levels of compliance. In the committee's view, individual providers, communities, and states must accept some level of responsibility for immunization and must be accountable for delivering those services. Public health agencies must be at the forefront of efforts to establish accountability for universal immunization and to work with providers in the public and private sectors to ensure the systematic delivery of services and assessment of performance. The lack of population-based data on children's immunization needs and the heterogeneous environment in which immunizations and other health care services are delivered in the United States will make it difficult to formalize these arrangements. To illustrate just one problem: when children receive care from a variety of unrelated providers, where should responsibility for immunization lie, and who should be held accountable?

Achieving accountability for immunization demands good information about children and their immunization status and about the delivery of immunization services. The committee emphasizes the importance of developing such information, which can be a powerful motivator. With evidence that children have not received recommended immunizations, policymakers, providers, and families all learn that action is needed and that they can be held accountable if it is not taken.

Accountability should be based on information about specific children and about groups of children. Interest in and work on registry systems, which can



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Overcoming Barriers to Immunization: A Workshop Summary 4 Accountability and Responsibility for Providing Immunizations Accountability for ensuring that all children are immunized has been missing but will be essential to reach the 1996 target of 90 percent immunization coverage among preschool children and to achieve and sustain higher levels of compliance. In the committee's view, individual providers, communities, and states must accept some level of responsibility for immunization and must be accountable for delivering those services. Public health agencies must be at the forefront of efforts to establish accountability for universal immunization and to work with providers in the public and private sectors to ensure the systematic delivery of services and assessment of performance. The lack of population-based data on children's immunization needs and the heterogeneous environment in which immunizations and other health care services are delivered in the United States will make it difficult to formalize these arrangements. To illustrate just one problem: when children receive care from a variety of unrelated providers, where should responsibility for immunization lie, and who should be held accountable? Achieving accountability for immunization demands good information about children and their immunization status and about the delivery of immunization services. The committee emphasizes the importance of developing such information, which can be a powerful motivator. With evidence that children have not received recommended immunizations, policymakers, providers, and families all learn that action is needed and that they can be held accountable if it is not taken. Accountability should be based on information about specific children and about groups of children. Interest in and work on registry systems, which can

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Overcoming Barriers to Immunization: A Workshop Summary be designed to provide both kinds of information, are growing with programs such as All Kids Count, independent registry efforts in several states and communities, and registry and tracking products from private vendors. The committee agrees with those who are encouraging the development of a national system of state-based immunization registries. CDC's new random-digit dialing telephone surveys will provide states with another source of information on children's immunization needs.1 (Information issues are addressed in greater detail later in this report.) A CENTRAL ROLE FOR STATES Although responsibility and accountability for immunization must exist at many levels, states have special obligations as holders of the authority to act to protect the public's health. Because the independent efforts of individual providers and communities cannot ensure comprehensive coverage, states must recognize that they have a responsibility to identify and correct gaps in immunization services. The committee believes that states must formulate immunization plans that systematically address the needs of all children and providers throughout the state in the short term and in the longer term. A broad range of interested parties should participate in the development and implementation of such plans: state and local public health departments, private providers, vaccine companies, payers, community groups, and families. State planning groups also must determine where responsibility for the desired outcomes should lie. Each state needs a unique plan that reflects its particular requirements and resources. States must assess children's immunization needs and ensure that public or private providers and clinics can provide the services to meet those needs. Finding children who have little contact with the health care system or other social services will pose a special challenge. Optimally, every child would have a medical home with a specific primary care provider, and providers would have responsibility for an identifiable set of children. David Salisbury, director of the immunization program in the United Kingdom, explained that these complementary steps are essential to the success of that program. Establishing formal and meaningful child-provider links for all children is more problematic in the United States, but it may succeed in the environment anticipated under some health care reform proposals. 1   The results of these surveys will, however, tend to overestimate coverage, because children in families that do not have telephones are more likely to be underimmunized than other children. Planned validation studies using immunization data from the National Health Interview Survey should help CDC compensate for these limitations.

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Overcoming Barriers to Immunization: A Workshop Summary State assessments should include determination of whether individual children are receiving appropriate immunizations on time and whether individual providers are giving the immunizations that their patients need. Both providers and public health authorities should monitor whether children have received immunizations and should follow-up with those who have not. States also must meet the needs of children who are eligible for but not enrolled in programs such as Medicaid and WIC. These children may lack a source of primary care that will provide immunizations and may the miss immunization services offered to children enrolled in such programs. Workshop participants expressed particular concern about the impact of managed care programs on children receiving Medicaid benefits. In Los Angeles, for example, some of the HMOs enrolling inner-city families have few providers in those neighborhoods. A review of California 's Medicaid managed care program found that reimbursement rates were inadequate to allow providers to deliver good care or to remain financially viable and that there was insufficient oversight of the program by the state. The Florida Medicaid program has received permission to exclude immunizations from its Early and Periodic Screening, Diagnostic, and Testing (EPSDT) program and to require referrals to public clinics, which provide vaccines free of charge. The number of children who actually receive their immunizations after referral to a public clinic is not known. States should work with providers to ensure that they have an accurate picture of the immunization services they are providing. Susan Lett reported that practice-based assessments in Massachusetts are showing many providers that they are immunizing a smaller proportion of children than they thought. The assessments are labor-intensive, and Lett and her staff now have more requests for assessments than they can conduct in a timely manner. They have found, however, that many private providers are unfamiliar with the capabilities of computer-based information systems and have little interest in office-based patient tracking systems, which would enable them to do their own assessments. MEETING THE DEMAND FOR IMMUNIZATION SERVICES Expectations that states, communities, providers, or parents will be held accountable for properly immunizing children must consider whether resources are available to provide those services. Workshop participants observed that often they are not. States have reported that they need funds to support additional staff, education and outreach activities, and infrastructure development if they are to achieve 90 percent immunization rates (ASTHO, 1992). Fewer than 60 percent of urban health departments surveyed by CityMatCH reported having the capacity to meet the demand for immunization services (Hubbert and Peck, 1993). As noted earlier, the limited number of health care providers in

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Overcoming Barriers to Immunization: A Workshop Summary rural Texas does not constitute an adequate delivery system for the available vaccines; the higher than expected number of penalties to AFDC participants under Maryland's program to encourage primary care for children appears to reflect difficulties in obtaining timely care (George, 1993); and the overall demand for ambulatory care exceeds the available provider capacity in Los Angeles. The lack of capacity in the public sector emphasizes that private providers are essential participants in delivering immunization services. Increased federal purchase of vaccines and more CDC grant funding may ease some financial problems, but an inadequate supply of providers may still limit the needed expansion of health care services to provide immunizations. ESTABLISHING ACCOUNTABILITY AND RESPONSIBILITY Steps to Take in the Short Term IAPs and state accountability. CDC can help states use Immunization Action Plans (IAPs) to promote state accountability for the immunization status of all children in their jurisdictions. The funding and other assistance associated with IAPs make them valuable tools for influencing the perceptions, expectations, and actions of state officials. A sense of accountability and interest in the success of IAP efforts needs to extend beyond health departments to governors and other senior state officials. IAPs and Vaccines for Children Program. The states can work with CDC to amend IAPs to reflect changes in federal law and the provisions of the Vaccines for Children Program. The IAP program called on states to find better ways to meet the immunization needs of all children. It is the basis for substantial federal support for state immunization efforts but was initiated before adoption of the Vaccines for Children Program. The conjunction of these two programs will give states additional funds and new opportunities to develop effective immunization programs. Primary care and immunization services. States can promote the development of more effective primary care services that will provide children's immunizations. Systematic integration of primary care and immunization services across the public and private sectors is needed. When primary care services are limited, linking immunization services in the public sector with other public services may be helpful. When the need for immunization services is urgent, states should consider locating immunization services with WIC and other public assistance programs or offering immunizations at other nontraditional locations. Special immunization services should not be allowed to divert attention from children's broader primary care needs.

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Overcoming Barriers to Immunization: A Workshop Summary IAPs can encourage states to do the comprehensive planning that assesses all available resources and how they can best be used. Planning groups that bring together public- and private-sector representatives can help optimize the effectiveness of the resources available in the private sector, which include not only providers but also organizations and individuals that can contribute funds and volunteers. Immunization data. States can encourage the collection of high-quality data on immunization needs and services. Unless data collected on children's immunizations are accurate and comprehensive, they will provide a misleading picture of how well (or poorly) children are immunized. Immunization registries and CDC's telephone surveys can become valuable sources of such data. Cooperation between public- and private-sector providers. Delivery of immunization services takes place at the local level. Therefore, local health departments need to promote effective cooperation between public- and private-sector providers. Steps to Take in the Longer Term Immunization incentives. States and communities can use Medicaid and other public payment systems to create incentives and promote provider accountability for immunization. HMOs or major purchasers of health services (such as large employers) also might be able to establish financial incentives for providers to achieve high levels of immunization within a defined population. The system developed in the United Kingdom, which provides strong financial incentives to providers to meet overall immunization targets, is one model that might be used. Providers in the United Kingdom receive a basic incentive payment only if they have immunized at least 70 percent of eligible children. They receive a substantially larger payment for a 90 percent level of immunization in their practices. Because providers receive these payments only if they achieve specific immunization levels for an entire group of eligible children assigned to their practices, they have a clear incentive to reach each and every child. Health services performance measures. Purchasers of capitated health care services (e.g., employers, state Medicaid programs, or, perhaps with health care reform, health alliances or similar groups) could include immunization services as a performance measure. When selecting plans, purchasers can consider whether those plans are meeting specified levels of immunization coverage for children of participants in the plans.