Preliminary Considerations Regarding Federal Investments in Vaccine Purchase and Immunization Services: Interim Report on Immunization Finance Policies and Practices (1999)

• vate insurance plans as their children mature (a process known as “cycling”), public health centers that provide a stable source of health services within communities may continue to play essential roles in serving disadvantaged groups.

• Vigilant attention to early childhood immunization coverage rates is necessary during the implementation stages of CHIP, since infants will immediately require immunization services. As a result, vaccines will still be needed in public health settings for needy families and others who do not qualify for, or are uncertain about their eligibility for, CHIP or Medicaid coverage.

• The complexity of the state CHIP plans; the intersection of CHIP programs, Medicaid, and the VFC program; and the emergence of managed care services within Medicaid increase the need for performance monitoring measures and information management resources at the state and national levels. As an insurance program, CHIP does not have the capacity to provide important immunization data collection, education, or program linkage services that offer population-wide benefits. Efforts to determine levels of immunization coverage within the state CHIP populations will need to draw upon datasets and measures (such as immunization registries and audits of public and private health records) supported by Section 317 infrastructure funds.

• Several external factors may influence the effectiveness of CHIP in meeting the immunization needs of underserved groups. For example, the vaccine discount rates negotiated through the VFC program represent important cost savings in the implementation of CHIP services. In addition, the initial negotiation of state contracts with managed care organizations in the implementation of CHIP includes several discretionary features regarding the scope of immunization services and record monitoring requirements. This variation in cost, coverage rates, and datasets yields significant uncertainty about the extent to which CHIP, by itself, will be able to improve immunization rates among disadvantaged families.

The IOM committee plans to engage in data collection efforts during the next 12 months to determine how state programmatic efforts contribute to an effective immunization system and how to finance productive efforts in the future. The committee's work will include a series of background papers, an analysis of state immunization policies and practices, and a state expenditure survey to identify areas of current investment in immunization efforts and to examine how federal budgetary practices influence state efforts. A series of site visits will also be conducted to provide additional documentation of state activities.

The IOM committee will recommend federal and state funding requirements for immunization programs in our final report in May 2000. As interim guidance, the Committee observes that:

• the Nation's immunization efforts are important and deserve careful attention,

• the current state of flux in new federal programs (such as CHIP) is generating considerable uncertainty about the role of governmental efforts in supporting and financing immunization services,

• as an insurance program, CHIP is not designed to support population-wide services in areas such as assessment of immunization coverage, professional and public education about vaccines, record assessment, or the development of immunization registries; and

• states have the capacity to use at least the current level of federal support from the national immunization program productively; any further reductions would threaten the provision of needed immunization services and would add further instability to a system in flux.

The task of immunizing the population of the United States is the responsibility of individual medical practitioners, state and local governments, and private organizations that constitute the decentralized health care system within this country. Reliance upon a patchwork health care system to provide immunization, and uneven and inconsistent investments in public health infrastructure foster circumstances in which ample opportunity exists for confusion and uncertainty in sustaining high levels of immunization coverage. Interactions among federal entitlements and discretionary programs, cost reimbursement policies, tax revenues, market forces, regulatory practices, and financial incentives all can contribute to—or impede—improvements in immunization rates. The committee's role will fbe to identify relevant knowledge and datasets that can illuminate the ways in which these interactions occur and guide future federal and state finance strategies for immunization efforts.

The committee recognizes that the mixture of public and private resources that undergirds the Nation's vaccine delivery system provides important lessons regarding the appropriate scope and limitations of public finance efforts. Increasingly, the public demands that we carefully balance governmental interventions against the role of the private health care sector. Some approaches may be more effective than others in achieving improvements in immunization coverage rates, and activities that are more appropriate for performance within the private sector should not be duplicated within government. Not all infrastructure efforts within the states require federal investments, but at present no strong methodology is available to distinguish among the priorities and areas of need included in the state budgetary requests. The committee 's final report will seek to identify knowledge about and experience with infrastructure roles and practices so that federal investments in immunization can be guided by data analysis, experience, and informed insights.