Appendix E
Overview of Case Studies and Site Visits

This overview describes the purpose and the methodology of the committee’s case studies and site visits. Information gathered through these efforts is incorporated in the body of the report, often featured in the boxes accompanying the text. A more detailed presentation of the findings of the individual case studies and site visits is contained in a forthcoming special issue of the American Journal of Preventive Medicine, (v. 19 [3S], October 2000) devoted to the research conducted in the development of this report.

The committee undertook eight state or locality-specific case studies in order to deepen the picture of local policy choices and performance of immunization programs and spending over the past decade. The state survey conducted for the committee by Dr. Gary Freed and associates provides a comprehensive view of the significant programmatic features and issues regarding immunization across the country (see Appendix D for a brief description of this survey). The individual case studies were designed to:

  • trace program changes, development, and performance over time,

  • collect detailed information on state- (and in the case of Los Angeles and San Diego, county-) level spending for immunization-related activities, and

  • document the impact of federal policy directions and funding levels on state programs over the past decade.



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Calling the Shots: Immunization Finance Policies and Practices Appendix E Overview of Case Studies and Site Visits This overview describes the purpose and the methodology of the committee’s case studies and site visits. Information gathered through these efforts is incorporated in the body of the report, often featured in the boxes accompanying the text. A more detailed presentation of the findings of the individual case studies and site visits is contained in a forthcoming special issue of the American Journal of Preventive Medicine, (v. 19 [3S], October 2000) devoted to the research conducted in the development of this report. The committee undertook eight state or locality-specific case studies in order to deepen the picture of local policy choices and performance of immunization programs and spending over the past decade. The state survey conducted for the committee by Dr. Gary Freed and associates provides a comprehensive view of the significant programmatic features and issues regarding immunization across the country (see Appendix D for a brief description of this survey). The individual case studies were designed to: trace program changes, development, and performance over time, collect detailed information on state- (and in the case of Los Angeles and San Diego, county-) level spending for immunization-related activities, and document the impact of federal policy directions and funding levels on state programs over the past decade.

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Calling the Shots: Immunization Finance Policies and Practices The sampling of states and localities is far too small to be statistically representative, and the findings of the case studies cannot be used by themselves to make national generalizations, at least as regards state-level program models and policy choices. Nevertheless, the case studies and site visits allowed the committee to pursue questions about the implementation of national program and funding policies across an array of states. They also gave committee members, staff, and consultants the opportunity to communicate directly with state and local immunization and health program managers in a sustained fashion on several occasions, which provided much insight into the impact and importance of federal policies. The sites chosen were Maine; New Jersey; North Carolina; Alabama; Michigan; Texas; Washington; and, in California, Los Angeles and San Diego Counties. These states and counties were selected because they vary demographically, and because their immunization policies and program structures reflect distinctive choices that convey a sense of the variety among all the states in immunization strategies, challenges, and achievements. Table E-1 displays notable demographic statistics for these states (California data are used for Los Angeles and San Diego Counties), Table E-2 shows immunization-related public policies and programmatic features; and Table E-3 displays Section 317, VFC, and state-source immunization spending for 1995 and 1998. The framework for developing profiles of individual states and the data elements to be collected for all cases were designed by staff and reviewed by the committee. A subcommittee to oversee the conduct of the case studies was formed, and members of this subcommittee, as well as members of the committee at large, participated in site visits and were involved in both the written and oral presentation of findings to the rest of the committee. Four site visits were conducted to large metropolitan areas known to have pockets of need and/or overall low immunization coverage rates: Detroit, Michigan; Newark, New Jersey; Houston, Texas; and Los Angeles and San Diego, California (a combined visit). Interviews with and visits to operating programs included the following in each of the sites: county and municipal immunization program and health directors, managed care organizations serving Medicaid and SCHIP clients, persons using or developing immunization registries,

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Calling the Shots: Immunization Finance Policies and Practices WIC clinics or coordinators, private-practice physicians, and managers and practitioners in federally qualified health care centers. The information gathered during the site visits was incorporated into each state’s case study. The case study reports were developed through interviews with state health department officials, including the immunization program directors, Medicaid agency staff, budget analysts, and CDC public health advisors to the state, among others. These interviews were, in most cases, coordinated with the initial telephone interview conducted by the research team for the state survey to minimize the imposition on the state respondent’s time and avoid duplication. In addition to the interviews with key program managers, the case study sites were asked to provide detailed information on state spending from all revenue sources for immunization activities for the period 1992 through 1998: federal grants, state revenues (in the case of Los Angeles and San Diego, county revenues as well), and foundation grants. Reconstruction of this historical information, broken out by category of spending (e.g., personnel, contracts, aid to counties) was extraordinarily difficult and labor-intensive for the state health departments, involving the efforts of their own budget analysts and sometimes state budget office staff. The cooperation the committee received from all of the studied states in retrieving and reporting this information was extraordinary as well. The detailed reports of spending on immunization activities comprise an essential element of the information base used by the committee in developing its findings and recommendations. Finally, the respective state grant applications to CDC for Section 317 funds for 1992, 1995, 1999, and 2000 were reviewed, providing another source of information over time for the case studies.

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Calling the Shots: Immunization Finance Policies and Practices TABLE E-1 Demographic Characteristics of Case Study States State Child Pop (thousands)a Birth Cohort (% National Cohort) b Region Fiscal Capacity Index (national rank)c Maine 297 13,669 (.35) New England 111 (19) New Jersey 1,987 113,279 (2.9) Mid-Atlantic 186 (1) North Carolina 1,873 107,015 (2.8) South 92 (31) Alabama 1,071 60,914 (1.6) South 68 (40) Michigan 2,506 133,714 (3.4) Midwest 88 (33) Texas 5,577 333,974 (8.6) South 62 (42) Washington 1,455 78,190 (2.0) North West 114 (17) California 8,952 524,840 (13.5) West 73 (38) Los Angeles 2,518g 175,000   San Diego   45,000   National 69,528 3,880,894   100 aPopulation data from 1997. Cited in Kids Count Data Book. The Annie E.Casey Foundation, 1999. bCited in National Vital Statistics Reports, 1997. 47(18):April 29, 1999. cState per capita income divided by number of poor children in state, 1995 data. Toby Douglas and Kimura Flores, Urban Institute, March 1998. TABLE E-2 State Program Characteristics State % in Medicaid Managed Carea FMAPb SCHIP Programc State Vaccine Purchase Maine 11 66% Mixed UPe New Jersey 59 50% Mixed non-UP North Carolina 69 63% Sep. plan UP Alabama 71 69% Mixed non-UP Michigan 68 54% Mixed Partial state purchase (for uninsured) Texas 25 62% Mixed Partial state purchase (for uninsured) Washington 91 52% Sep. plan UP California 46 51% Mixed non-UP Los Angeles San Diego a1998 Managed Care Enrollment, www.hcfa.gov/medicaid/mcstat98.htm. bFMAP=Federal Medical Assistance Percentage, or federal matching rate for Medicaid service expenditures, at www.hcfa.gov.medicaid. cSCHIP Plan Activity Map, 4/24/2000, at www.hcfa.gov/init/chip-map.htm.

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Calling the Shots: Immunization Finance Policies and Practices % Children w/Medicaidd % Children Uninsurede % Non-White Births % Children <100% FPLf 20 13 7 14 16 14 42 14 27 15 35 19 22 15 35 24 25 8 30 19 24 24 59 25 25 9 28 15 29 18 66 35 25 14 40 20 dPercentage data from 1996. Cited in Kids Count Data Book. The Annie E.Casey Foundation, 1999. eCited in Kids Count Data Book. The Annie E.Casey Foundation, 1999. fFPL=federal poverty level. gPopulation data for Los Angeles County from U.S. Bureau of the Census, July 1, 1995. Medicaid Vaccine Admin. Fee First $ Coverage Required for Private Insurers 1998 Statewide Immunization Rates 1998 Metro Area Immunization Rates for Children≤FPLd $5.00 No 89%   $11.50 in MCOf rates, passed thru Yes 85% Newark: 71.4% $13.71/1 dose; double for>2 No 84%   $8.00/dose No 84% Jefferson County: 90.5% $7/injection; HMOs only 79% Detroit: 72% $3/oral $5.00 Yes for plans since 1/98; no small employers 75% Houston: 55%; Dallas: 69% $5.00 No 81%   $7.50/dose Yes 78%     67%   73.5% dFPL=federal poverty level. eUP=universal purchase. fMCO=managed care organization.

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Calling the Shots: Immunization Finance Policies and Practices TABLE E-3 Section 317, VFC, and State Immunization Spending (dollars in millions [dollar per birth cohort member])   Vaccine Purchase   317 DA 1995 317 DA 1998 VFC DA 1995 VFC DA 1998 State Revs 1995 State Revs 1998 Maine 0.682 1.883 1.26 1.592 included in infrastructure ($/birth cohort) [47.23 137.76 87.25   116.47]   New Jersey 1.673 1.916 2.654 3.259 0.02 0.02   [14.24 16.91 22.59 28.77 0.17 0.18] North Carolina 1.985 3.154 4.129 10.92 7.875 10.737   [19.57 29.47 40.71 102.04 77.65 100.33] Alabama 3.54 2.265 4.941 7.06 1 0.4   [58.09 37.18 81.08 115.9 16.41 6.57] Michigan 4.987 10.463 9.071 12.742 3.911 0.101   [36.13 78.25 65.72 95.29 28.33 0.76] Texas 6.476 9.098 28.023 34.524 19.863 13.731 [20.17 27.24 87.27 103.37 61.86 41.11] Washington 2.512 3.266 3.106 6.008 3.534 7.082   [32.47 41.77 40.15 76.84 45.68 90.57] California 6.987 9.241 51.319 72.555     [13.31 17.61 97.78 138.24]   Los Angeles   0.099   [0.57] San Diego   0.05   [1.11] National 96.304 135.562 247.692 399.974     [24.36 34.93 62.65 103.06]   NOTE: Los Angeles and San Diego include county as well as state spending. Texas includes separate 317 grants to Houston and San Antonio. SOURCES: CDC, National Immunization program data for 317 and VFC. IOM case study data for state and local immunization spending. 1994 and 1997 birth cohorts: National Center for Health Statistics, Vital Health Statistics.

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Calling the Shots: Immunization Finance Policies and Practices Infrastructure 317 FA 1995 317 FA 1998 VFC FA 1995 VFC FA 1998 State Revs 1995 State Revs 1998 1.228 1.665 0.233 0.495 0.1 0.5 [85.04 121.81 16.13 34.28 $6.92 36.58] 2.502 4.071 1.692 1.505 0.482 0.94 [21.29 35.94 14.4 13.29 4.1 8.3] 5.765 4.14 0.334 0.375 1.639 1.482 [56.84 38.69 3.29 3.5 16.16 13.85] 2.97 3.194 0.387 0.439 0.6 0.6 [48.74 52.43 6.35 7.21 9.85 9.85] 6.376 6.2 2.453 1.435 0.647 4.046 [46.19 46.37 17.77 10.73 4.69 30.26] 8.58 13.925 0.965 2.07 16.251 8.779 [26.72 41.69 3.01 6.2 50.61 26.29] 4.52 3.231 0.285 0.87 0.352 0.423 [58.43 41.32 3.68 11.13 4.55 5.11] 23.427 18.312 1.205 1.974   [44.64 34.89 2.3 3.76]     0.426 2.308   [13.19]   1.992 3.374   [74.98] 195.405 186.149 23.288 29.475   [49.42 47.97 5.89 7.59]  

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Calling the Shots: Immunization Finance Policies and Practices BOX E-1 Case Study Summary The following authors prepared the eight case studies discussed in this report: Alabama—Roy Hogan, M.P.A., Consultant, Austin, Texas Maine—Kay Johnson, Ed.M., M.P.H., Johnson Group Consultants, Inc., Hinesburg, Vt. Michigan—Hanns Kuttner, M.A., School of Public Policy Studies, University of Chicago New Jersey—Gerry Fairbrother, Ph.D., Associate Professor of Epidemiology and Social Medicine, Montefiore Medical Center, New York City, and Paul Meissner, M.S.P.M., and Alana Balaban, B.Sc., Division of Epidemiology and Social Medicine, Montefiore Medical Center, New York City North Carolina—Wilhelmine Miller, M.S., Ph.D., Program Officer, Institute of Medicine Texas—Roy Hogan, M.P.A., Consultant, Austin, Texas Washington—Heather McPhillips, M.D., M.P.H., Department of Pediatrics, University of Washington, and E.Russell Alexander, M.D., M.P.H., Professor Emeritus, School of Public Health, University of Washington Comparison of Los Angeles and San Diego Counties, California— Gerry Fairbrother, Ph.D., Associate Professor of Epidemiology and Social Medicine, Montefiore Medical Center, New York City, and Elka Munizaga, Division of Epidemiology and Social Medicine, Montefiore Medical Center, New York City The case studies are available on line at www.books.nap.edu/catalog/9836.html. A summary article of the case study findings appears in the American Journal of Preventive Medicine (Fairbrother et al., forthcoming).