The incidence, prevalence, and mortality of once lethal communicable diseases have greatly diminished due to comprehensive immunization strategies. Vaccinations have proven to be one of the most effective public health strategies to control and prevent the onset of illness. Studies have estimated that for each U.S. birth cohort receiving recommended childhood immunizations, around 20 million illnesses and more than 40,000 deaths are prevented, resulting in $70 billion in savings.
Despite the widespread availability of vaccines, multiple resurgences of measles, rubella, mumps, and pertussis have occurred since the 1980s. A current example of this being the measles outbreak in the United States. Despite measles being declared eradicated in the United States in 2000, from January 1 to April 11, 2019 there have been at least 555 confirmed cases. Washington is one of the 20 states, reporting cases, as well as one that allows nonmedical exemptions for vaccines (i.e., for philosophical or personal reasons). However, there is now debate over banning these exemptions.
The measles outbreak is due to an increase in the number of travelers who caught measles abroad and brought it back to the U.S. and the spread of measles in local communities that have unvaccinated people, but there are many other challenges states are working to address in order to increase immunization rates – from inadequate provider access to proper recording of immunizations given. With funding from the Centers for Disease Control and Prevention, AcademyHealth is working with the National Academy for State Health Policy (NASHP) and the Colorado Children’s Immunization Coalition (CCIC) to address these challenges through formation of a Community of Practice (CoP). The CoP is comprised of five states’ Medicaid, and public health agency immunization programs collaborating to improve immunization rates for children and pregnant women with Medicaid coverage.
The first year of this CoP engagement identified variable immunization policy landscapes across states. While each state shares an interest in improving immunization rates, there are differences in how states can respond to increase coverage based on their Medicaid programs and policies, data infrastructure and environmental contexts. The project’s environmental scan identified three areas of opportunity including leveraging data, ensuring access and coverage, and enhancing provider/patient education and engagement.
Leveraging Data
As noted through the project’s environmental scan, all CoP states measure child and adolescent vaccination rate indicators, but data collection rates ranged dramatically from 48 percent to 96 percent based on the quality of data collection. Furthermore, these states had limited to no reporting of specific Maternal and Child Health Indicators, such as the number of pregnant women on Medicaid due to the scant clinical information (e.g., estimated due date, date of last menstrual period, date of delivery) reported on health insurance claims , which is necessary to accurately identify pregnant women.
All five states (CO, HI, KY, MT, NM) participating in the CoP share a common goal to increase their data collection by improving the infrastructure of their immunization information system (IIS). These systems are confidential, population-based databases that record all immunization doses administered by participating providers to persons residing within a given area. An IIS with complete, high-quality data is a powerful tool for assessing statewide or local area vaccination coverage, enabling targeted vaccination efforts in areas with lower coverage. IIS data quality and completeness depend on the regular submission of immunization data by providers. Data submission to the IIS increasingly relies on electronic data exchange between provider electronic health records and the IIS. Once providers are submitting data, efforts can be undertaken to improve data quality. Medicaid match funding can support staffing, improve electronic data exchange, and advance data quality improvement efforts to improve an IIS’s capacity.
“We’ve gained valuable insights about how to more effectively leverage information technology, engage providers to close gaps in evidence based practice, overcome patient misunderstandings about vaccines, and sustainable finance preventive health services.” – Dr. Gil Liu, Chief Medical Officer for Kentucky’s Department of Medicaid Services.
The CoP states have strategized linking maternal and infant records within the same data source or linking claims data to vital records and electronic medical records. However, these types of data linkages are not always feasible for states. Rather, states recommend a less intensive strategy by leveraging patient health records with the ability to institute recall systems for the provider, reminding them of their patient’s immunization needs and enabling this information to be relayed to said patient.
Ensuring Access and Coverage
Project interviews with the CoP states identified access and coverage as critical challenges spanning issues from rural access to providers to financial implications related to Vaccines for Children (VFC) provider participation to state scope of practice policies that delegate what type of provider can administer vaccines.
To address these issues, the project team is targeting technical assistance (TA) to CoP states, among other areas, to inform the use of additional providers (e.g. ob-gyns, pediatricians, internists, pharmacists) as vaccinators. We are also identifying successful examples of states that require IIS participation, which resulted in the onboarding of more providers and/or increased coverage, improved documentation and increased vaccine reimbursement.
There are also a multitude of patient strategies states could engage in to increase access, such as home visits, expanding the number of community vaccine clinics, and creating family incentives for receiving their annual immunizations. Finally, in the future, it would be beneficial to create interventions or programs that target the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) populations, as a series of immunizations are recommended for children from birth to 2 years of age, which coincides with the period in which many low-income children participate in WIC.
Some CoP states have adopted such policies into practice by increasing collaboration between various health departments, partnering with associations, such as state American College of Obstetricians & Gynecologists state chapters, and advocacy organizations to increase awareness, promote education, and support data sharing across agencies.
Enhancing Education and Engagement
Low vaccine reimbursement rates have been a barrier to higher provider engagement in the VFC program, however educating providers on the return on investment (ROI) and overall benefit in administering vaccines is a strategy states are pursuing. This first year of the CoP has raised visibility on the varied vaccine reimbursement rates for Medicaid providers across states, and it is an area of continued interest and research for the duration of the project. Beyond reimbursement, some providers do not have the time or resources to add an additional service, and compliant vaccine supply, to their care routine, especially from a financial perspective. Providers understand the benefit of immunizations, but as mentioned above, increasing scope of practice to other healthcare workers may entice additional engagement in VFC (e.g. ob-gyns, pediatricians, internists, pharmacists). Increasing provider vaccine engagement is still an area of interest where CoP states are formulating strategies.
As the anti-vaccine movement has become more prominent among younger families, education and promotion about the benefits of vaccines should be more robust. Strategies include training providers on how to have a productive dialogue with parents, ensure parents and patients understand the importance of vaccines, and have access to clinics or pharmacies nearby that provide vaccination services. States should consider creating stricter vaccine requirements, such as adopting more stringent exemption standards for childcare and school enrollment from preschool to college, as Washington State is considering in lieu of these recent outbreaks.
Over the next two years, the CoP states will continue to address specific barriers directly through enhancing their capacity to collect complete immunization data, identifying their at-risk populations, and begin targeting their provider and patient-focused strategies. With the recent outbreaks around the country this work will be beneficial to other states that are tackling similar issues.