Association between Medicaid reimbursement and child influenza vaccination rates

Employees' seeking preference towards influenza vaccination in organization: A discrete choice experiment in China

To clarify the preferences of employees seeking influenza vaccination, a discrete choice experiment aims to understand the essential factors that close the gap between intention and behavior. A total of 866 employees with vaccination willingness willing to participated in a discrete choice experiment (DCE) between October 31st and December 6th, 2022 in China including the following attributes: price, vaccination setting, appointment mode, and service time. The data was analyzed using mixed logit models. Employees from smaller enterprises were more likely to get vaccinated collectively. For employees willing to get the influenza vaccine, 95.08 % of their choice was dominated by price. Employees' behavior varied according to their socioeconomic characteristics. Only female employees strongly favored work-site-based vaccination. Price was the primary factor considered by employees for getting the influenza vaccine. DCE would help to develop influenza vaccination intervention targeted at different groups in future studies.

Pediatric influenza vaccination rates lower than previous estimates in the United States

BACKGROUND

Annually, pediatric influenza vaccination coverage estimates are ascertained from health surveys, such as the National Immunization Survey (NIS-Flu). From 2010 to 2017, vaccination coverage among children ranged from 51 to 59 %. Recognizing the limitations of national health survey data, we sought to describe temporal trends in pediatric influenza vaccination coverage, and demographic differences among a commercially insured large national cohort from 07/01/2010 to 06/30/2017.

METHODS

Influenza vaccination coverage was assessed among children (<18 years) with continuous enrollment in the de-identified Optum Clinformatics® Data Mart database, and from NIS-Flu. Time trends in vaccination coverage were assessed using Joinpoint regression, overall and stratified by age group, sex, and geographic region.

RESULTS

The average annual pediatric influenza vaccination coverage was 33.4 % in our study population versus 56.5 % reported from NIS-Flu during the same period (p-value < 0.0001). Vaccination coverage was highest in children 6 months-4-years old at 52.6 % (versus 68.8 % NIS-Flu, p-value < 0.0001), and lowest in the 13-17-year-old age group at 20.1 % (versus 42.8 % NIS-Flu, p-value < 0.0001). Vaccination coverage over time remained stable in our study population (average annual percent change 1.8 %, 95 % confidence interval [CI] -2.3 % to 6.0 %) versus significantly increasing by 2.8 % in NIS-Flu (95 % CI 0.3 % to 5.3 %).

CONCLUSIONS

Vaccination coverage in our commercially insured pediatric population was 51.4% lower than estimates from NIS-Flu during the same period, suggesting the need for more accurate vaccination coverage surveillance, which will also be critical in future COVID-19 vaccination efforts. Effective interventions are needed to increase pediatric influenza vaccination rates to the Healthy People 2020 target of 70%.

Willingness to Pay for Seasonal Influenza Vaccination among Children, Chronic Disease Patients, and the Elderly in China: A National Cross-Sectional Survey

Background: The disease burden of seasonal influenza is substantial in China, while the vaccination rate is extremely low, and most people have to pay 100% for vaccination. This study aims to examine willingness to pay (WTP) and recommended financing sources for influenza vaccination among children, chronic disease patients, and the elderly in China and determine feasible measures to expand vaccination coverage. Methods: From August to October 2019, 6668 children's caregivers, 1735 chronic disease patients, and 3849 elderly people were recruited from 10 provinces in China. An on-site survey was conducted via a especially designed PAD system. Tobit regression was adopted to predict the influencing factors of WTP. Results: The average WTP was 127.5 yuan (USD18.0) for children, 96.5 yuan (USD13.7) for chronic disease patients, and 88.1 yuan (USD12.5) for the elderly. Most participants in the three groups thought government subsidies (94.8%, 95.8%, and 95.5%) or health insurance (94.3%, 95.3%, and 94.5%) should cover part of the cost, and nearly four-fifths (80.1%, 79.5%, and 76.8%) believed that individuals should also pay for part. Tobit regression showed that a higher perceived importance of vaccination, knowing about priority groups, and considering that individuals should co-pay were promoters of WTP, while considering price as a hindrance lowered WTP. Conclusions: The WTP for influenza vaccination among children, chronic disease patients, and the elderly in China is fairly high, suggesting that price is not the primary hindrance and there is room to expand immunization. Most participants expected the government and/or health insurance to pay part of the cost, and such supportive funding could act as a promotive policy "signal" to improve vaccine uptake. Influenza-related health education is also needed to expand vaccine coverage.

The Impact of Changes in Medicaid Provider Fees on Provider Participation and Enrollees' Care: a Systematic Literature Review

BACKGROUND

Changing Medicaid fees is a common approach for states to address budget fluctuations, and many currently set Medicaid physician fees at levels lower than Medicare and private insurers. The Affordable Care Act included a temporary Medicaid fee bump for primary care providers (PCPs) in 2013-2014 that recently led to both an increase and then subsequent decrease in PCP fees in many states.

OBJECTIVE

To conduct a systematic literature review on the effects of changing Medicaid fees on provider participation and enrollees' access to care and service use.

METHODS

We searched PubMed/Medline and JSTOR and identified 18 studies that assessed the longitudinal impact of provider fee changes in Medicaid on the outcomes of interest. We summarized information on study design, methods, and findings.

RESULTS

Seven studies examined the impact of fee changes on provider participation in Medicaid. Of these, three studies found that fee increases were associated with positive effects on providers' likelihood of accepting Medicaid patients or on their Medicaid caseloads. Five studies that examined the impact of fee changes on Medicaid enrollees' access to care found a positive association with one or more access measure, such as having a usual source of care or appointment availability. Lastly, eight of 14 studies that examined service use found positive associations between fee changes and at least one measure of use, such as changes in the probability of enrollees having any visit, the number of visits, and shifts in the site of care toward office-based care; others largely did not find significant associations.

CONCLUSIONS

There is mixed evidence on the impact of changing Medicaid fees on provider participation and enrollees' service use; however, increasing fees appears to have more consistent positive effects on access to care. Whether these improvements in access translate into better health outcomes or downstream cost savings are critical questions.

Screening for Behavioral Risk Factors Is Not Enough to Improve Preventive Services Delivery

OBJECTIVE

Unhealthy behaviors are a major cause of chronic disease. Preappointment screening has been suggested as one way to improve preventive care delivery related to these behaviors by specifying risks to be addressed. We aimed to determine whether screening for health-related behaviors before the clinical encounter will lead to higher counseling rate and service delivery by clinicians.

METHODS

We used a pre/post design in one practice with a control practice to evaluate the effects of preappointment screening for 3 behavioral risk factors (tobacco smoke exposure, no recent dental care visit, and consumption of sugar-sweetened beverages). After their clinic visit, we asked English-speaking parents whose child had one or more risk factor whether they had received counseling or services from their pediatrician to address them.

RESULTS

We recruited 264 parents in the pre phase and 242 in the post phase. Among 215 parents whose child had one or more risk factors, parents in the post phase were as likely to report receiving counseling than parents in the pre phase for each of the risk factors: smoking odds ratio 6.75 (95% confidence interval, 0.51, 88.88), dental health odds ratio 1.44 (95% confidence interval, 0.47, 4.41), and sugar-sweetened beverage consumption odds ratio 0.34 (95% confidence interval, 0.23, 5.18). Service delivery and reported behavior change were also similar in both phases.

CONCLUSIONS

Counseling rates for tobacco, dental health, or sugar-sweetened beverage consumption were low in pediatric primary care, and preappointment screening did not significantly affect clinician counseling. Future efforts will require a more robust approach to effect change in counseling, provision of service, and family behavior.

Payments and Utilization of Immunization Services Among Children Enrolled in Fee-for-Service Medicaid

OBJECTIVE

To examine the association between state Medicaid vaccine administration fees and children's receipt of immunization services.

METHODS

The study used the 2008-2012 Medicaid Analytic eXtract data and included children aged 0-17 years and continuously enrolled in a Medicaid fee-for-service plan in each study year. Analyses were restricted to 8 states with a Medicaid managed-care penetration rate <75%. Linear regressions were used to estimate the probability of children making ≥1 vaccination visit and the numbers of vaccination visits in the year as a function of state Medicaid vaccine administration fees, age group, sex, race/ethnicity, state unemployment rate, state managed-care penetration rate, and state and year-fixed effects.

RESULTS

A total of 1,678,288 children were included. In 2008-2012, the average proportion of children making ≥1 vaccination visit per year was 31% and the mean number of vaccination visits was 0.9. State Medicaid reimbursements for vaccine administration was positively associated with immunization service utilization; for every $1 increase in the payment amount, the probability of children making ≥1 vaccination visit increased by 0.72 percentage point (95% confidence interval, 0.23-1.21; P=0.01), representing a 2% increase from the mean and the number of vaccination visits increased by 0.03 (95% confidence interval, -0.00 to 0.06; P<0.1). The estimated effect was greater among younger children.

CONCLUSION

Higher Medicaid reimbursements for vaccine administration were associated with increased proportion of children receiving immunization services.

Psychosocial Influences on Parental Decision-Making Regarding Vaccination Against Seasonal Influenza for Young Children in Hong Kong: a Longitudinal Study, 2012-2013

PURPOSE

Vaccination uptake remained low, although annual subsidies are provided to encourage 6-72-month-old Hong Kong children to be vaccinated against seasonal influenza. This study was aimed to investigate the psychosocial influences on parental decision-making regarding young children's seasonal influenza vaccination.

METHODS

One-thousand two-hundred twenty-six parents of eligible children were recruited using random digit dialing in August-October 2012 to assess baseline perceptions and re-contacted in March 2013 to record children's vaccination uptake. Structural equation modeling (SEM) was performed to examine factors associated with parental decision about children's vaccination based on the complete data of 1222 respondents.

RESULTS

Of the 1226 respondents who completed the follow-up survey, 34.3 % reported that their child was vaccinated during the follow-up period. Child's past influenza vaccination history (β = 0.48), belief in vaccination safety (β = 0.35), and social norms (β = 0.25) were strongly associated with parental intention to vaccinate their child which directly predicted child vaccination uptake (β = 0.57). Belief in vaccination safety (β = 0.42) and social norms (β = 0.36) were strongly associated with vaccination intention of parents whose children never received influenza vaccine.

CONCLUSION

Interventions that address concerns on vaccination safety and utilize social norms may be effective to initiate Chinese parents to vaccinate their children.

Storytelling in the context of vaccine refusal: a strategy to improve communication and immunisation

The December 2014 outbreak of measles in California impacted over 100 children and served as a reminder that this disease still plagues the USA, even 50 years following the first licensed vaccine. Refusal of vaccination is a complicated and multifaceted issue, one that clearly demands a closer look by paediatricians and public health officials alike. While medical doctors and scientists are trained to practice 'evidence-based medicine', and studies of vaccine safety and efficacy speak the language of statistics, there is reason to believe that this is not the most effective strategy for communicating with all groups of parents. Herein, we consider other methods such as narrative practices that employ stories and appeal more directly to parents. We also examine how doctors are trained to disseminate information and whether there are reasonable supplementary methods that could be used to improve vaccine communication and ultimately immunisation rates.

Out-of-pocket payments and community-wide health outcomes: an examination of influenza vaccination subsidies in Japan

While studies have shown that reductions in out-of-pocket payments for vaccination generally encourages vaccination uptake, research on the impact on health outcomes has rarely been examined. Thus, the present study, using municipal-level survey data on a subsidy programme for influenza vaccination in Japan that covers the entire country, examines how reductions in out-of-pocket payments for vaccination among non-elderly individuals through a subsidy programme affected regional-level influenza activity. We find that payment reductions are negatively correlated with the number of weeks with a high influenza alert in that region, although the correlation varied across years. At the same time, we find no significant correlation between payment reductions and the total duration of influenza outbreaks (i.e. periods with a moderate or high alert). Given that a greater number of weeks with a high alert indicates a severer epidemic, our findings suggest that reductions in out-of-pocket payments for influenza vaccination among the non-elderly had a positive impact on community-wide health outcomes, indicating that reduced out-of-pocket payments contributes to the effective control of severe influenza epidemics. This suggests that payment reductions could benefit not only individuals by providing them with better access to preventive care, as has been shown previously, but also communities as a whole by shortening the duration of epidemics.

Influenza Vaccination Among US Children With Asthma, 2005-2013

BACKGROUND

Children with asthma face higher risk of complications from influenza. Trends in influenza vaccination among children with asthma are unknown.

METHODS

We used 2005-2013 National Health Interview Survey data for children 2 to 17 years of age. We assessed, separately for children with and without asthma, any vaccination (received August through May) during each of the 2005-2006 through 2012-2013 influenza seasons and, for the 2010-2011 through 2012-2013 seasons only, early vaccination (received August through October). We used April-July interviews each year (n = 31,668) to assess vaccination during the previous influenza season. Predictive margins from logistic regression with time as the independent and vaccination status as the dependent variable were used to assess time trends. We also estimated the association between several sociodemographic variables and the likelihood of influenza vaccination.

RESULTS

From 2005 to 2013, among children with asthma, influenza vaccination receipt increased about 3 percentage points per year (P < .001), reaching 55% in 2012-2013. The percentage of all children with asthma vaccinated by October (early vaccination) was slightly above 30% in 2012-2013. In 2010-2013, adolescents, the uninsured, children of parents with some college education, and those living in the Midwest, South, and West were less likely to be vaccinated.

CONCLUSIONS

The percentage of children 2 to 17 years of age with asthma receiving influenza vaccination has increased since 2004-2005, reaching approximately 55% in 2012-2013.

Association of Influenza Vaccination Coverage in Younger Adults With Influenza-Related Illness in the Elderly

BACKGROUND

Older adults have the highest influenza-related morbidity and mortality risk, but the influenza vaccine is less effective in the elderly. It is unknown whether influenza vaccination of nonelderly adults confers additional disease protection on the elderly population.

METHODS

We examined the association between county-wide influenza vaccination coverage among 520 229 younger adults (aged 18-64 years) in the Behavioral Risk Factors Surveillance System Survey and illnesses related to influenza in 3 317 709 elderly Medicare beneficiaries aged ≥65 years, between 2002 and 2010 (13 267 786 person-years). Results were stratified by documented receipt of a seasonal influenza vaccine in each Medicare beneficiary.

RESULTS

Increases in county-wide vaccine coverage among younger adults were associated with lower adjusted odds of illnesses related to influenza in the elderly. Compared with elderly residents of counties with ≤15% of younger adults vaccinated, the adjusted odds ratio for a principal diagnosis of influenza among elderly residents was 0.91 (95% confidence interval, .88-.94) for counties with 16%-20% of younger adults vaccinated, 0.87 (.84-.90) for counties with 21%-25% vaccinated, 0.80 (.77-.83) for counties with 26%-30% vaccinated, and 0.79 (.76-.83) for counties with ≥31% vaccinated (P for trend <.001). Stronger associations were observed among vaccinated elderly adults, in peak months of influenza season, in more severe influenza seasons, in influenza seasons with greater antigenic match to influenza vaccine, and for more specific definitions of influenza-related illness.

CONCLUSIONS

In a large, nationwide sample of Medicare beneficiaries, influenza vaccination among adults aged 18-64 years was inversely associated with illnesses related to influenza in the elderly.

Burden of vaccine-preventable disease in adult Medicaid and commercially insured populations: analysis of claims-based databases, 2006–2010

Vaccination rates among United States (US) adults are suboptimal, resulting in morbidity, mortality, and financial burden attributable to potentially vaccine-preventable diseases (VPDs). Unadjusted annual incidence proportions of VPDs were estimated for Medicaid and commercially insured adults aged 19-64 years using 2006-2010 claims, along with age/gender-adjusted incidence proportions for 2010. In 2010, 1.6 million Medicaid adults (mean age 34 ± 12 years; 73.4% female) and 33 million commercially insured (mean age 42 ± 13 years; 52.2% female) were included. Age/gender-adjusted incidence proportions (per 100 000) in 2010 among Medicaid vs commercially insured adults for meningococcal disease were 26.2 (95% CI 22.9-29.8) vs 2.0 (1.9-2.2) (P < 0.001); hepatitis B 88.9 (82.6-95.6) vs 17.5 (17.0-17.9) (P < 0.001); pneumococcal disease 98.2 (91.7-105.1) vs 21.1 (20.7-21.6) (P < 0.001); hepatitis A 19.8 (16.9-23.1) vs 4.5 (4.3-4.7) (P < 0.001); mumps 2.1 (1.3-3.3) vs 1.4 (1.3-1.6) (P = 0.14); measles 0.3 (0.1-1.0) vs 0.3 (0.2-0.3) (P = 0.38); herpes zoster (60- to 64-year-olds only) 459 (408-515) vs 473 (466-481) (P = 0.35); varicella (19- to 39-year-olds only) 6.5 (4.8-8.5) vs 8.0 (7.5-8.5) (P = 0.12); influenza 586 (573-598) vs 633 (631-636) (P < 0.001); and pertussis 1.8 (1.1-2.8) vs 3.2 (3.0-3.4) (P < 0.001). Research is needed to fully understand the causes of the disparity of the coded incidence of some VPDs in adult Medicaid population than commercially insured adults in the US.

Trends in childhood influenza vaccination coverage--U.S., 2004-2012

OBJECTIVE

We compared estimates of childhood influenza vaccination coverage by health status, age, and racial/ethnic group across eight consecutive influenza seasons (2004 through 2012) based on two survey systems to assess trends in childhood influenza vaccination coverage in the U.S.

METHODS

We used National Health Interview Survey (NHIS) and National Immunization Survey-Flu (NIS-Flu) data to estimate receipt of at least one dose of influenza vaccination among children aged 6 months to 17 years based on parental report. We computed estimates using Kaplan-Meier survival analysis methods.

RESULTS

Based on the NHIS, overall influenza vaccination coverage with at least one dose of influenza vaccine among children increased from 16.2% during the 2004-2005 influenza season to 47.1% during the 2011-2012 influenza season. Children with health conditions that put them at high risk for complications from influenza had higher influenza vaccination coverage than children without these health conditions for all the seasons studied. In seven of the eight seasons studied, there were no significant differences in influenza vaccination coverage between non-Hispanic black and non-Hispanic white children. Influenza vaccination coverage estimates for children were slightly higher based on NIS-Flu data compared with NHIS data for the 2010-2011 and 2011-2012 influenza seasons (4.1 and 4.4 percentage points higher, respectively); both NIS-Flu and NHIS estimates had similar patterns of decreasing vaccination coverage with increasing age.

CONCLUSIONS

Although influenza vaccination coverage among children continued to increase, by the 2011-2012 influenza season, only slightly less than half of U.S. children were vaccinated against influenza. Much improvement is needed to ensure all children aged ≥ 6 months are vaccinated annually against influenza.

School-located influenza vaccination with third-party billing: outcomes, cost, and reimbursement

OBJECTIVE

To assess rates of immunization; costs of conducting clinics; and reimbursements for a school-located influenza vaccination (SLIV) program that billed third-party payers.

METHODS

SLIV clinics were conducted in 19 elementary schools in the Denver Public School district (September 2010 to February 2011). School personnel obtained parental consent, and a community vaccinator conducted clinics and performed billing. Vaccines For Children vaccine was available for eligible students. Parents were not billed for any fees. Data were collected regarding implementation costs and vaccine cost was calculated using published private sector prices. Reimbursement amounts were compared to costs.

RESULTS

Overall, 30% of students (2784 of 9295) received ≥1 influenza vaccine; 39% (1079 of 2784) needed 2 doses and 80% received both. Excluding vaccine costs, implementation costs were $24.69 per vaccination. The percentage of vaccine costs reimbursed was 62% overall (82% from State Child Health Insurance Program (SCHIP), 50% from private insurance). The percentage of implementation costs reimbursed was 19% overall (23% from private, 27% from Medicaid, 29% from SCHIP and 0% among uninsured). Overall, 25% of total costs (implementation plus vaccine) were reimbursed.

CONCLUSIONS

A SLIV program resulted in vaccination of nearly one third of elementary students. Reimbursement rates were limited by 1) school restrictions on charging parents fees, 2) low payments for vaccine administration from public payers and 3) high rates of denials from private insurers. Some of these problems might be reduced by provisions in the Affordable Care Act.

Factors associated with in-office influenza vaccination by U.S. pediatric providers

BACKGROUND

In the United States, influenza vaccination is recommended for all children 6 months and older; however, vaccination rates are below target levels. A broad sample of U.S. pediatric offices was assessed to determine factors that influence in-office influenza vaccination rates.

METHODS

Offices (N = 174) were recruited to participate in an observational study over three influenza seasons (2008-2009, 2009-2010, 2010-2011). Only data from the first year of an office's participation in the study were used. Associations of coverage and 2-dose compliance rates with office characteristics and selected vaccination activities were examined using univariate regression analyses and linear regression analyses using office characteristics identified a priori and vaccination activities with P values ≤ 0.10 in univariate analyses.

RESULTS

Influenza vaccination coverage for children 6 months to 18 years of age averaged 25.2% (range: 2.0%-69.1%) and 2-dose compliance for children < 9 years of age averaged 53.4% (range: 5.4%-96.2%). Factors associated with increased coverage were non-rural site (P = 0.025), smaller office size (fewer than 5000 patients; P < 0.001), use of evening and weekend hours to offer influenza vaccine (P = 0.004), a longer vaccination period (P = 0.014), and a greater influenza vaccine coverage rate among office staff (P = 0.012). Increased 2-dose compliance was associated with smaller office size (P = 0.001) and using patient reminders (P = 0.012) and negatively related to use of electronic provider reminders to vaccinate (P = 0.003).

CONCLUSIONS

To maximize influenza vaccine coverage and compliance, offices could offer the vaccine during evening and weekend hours, extend the duration of vaccine availability, encourage staff vaccination, and remind patients that influenza vaccination is due. Additional efforts may be required in large offices and those in rural locations.

Guiding Principles for Managed Care Arrangements for the Health Care of Newborns, Infants, Children, Adolescents, and Young Adults

By including the precepts of primary care and the medical home in the delivery of services, managed care can be effective in increasing access to a full range of health care services and clinicians. A carefully designed and administered managed care plan can minimize patient under- and overutilization of services, as well as enhance quality of care. Therefore, the American Academy of Pediatrics urges the use of the key principles outlined in this statement in designing and implementing managed care programs for newborns, infants, children, adolescents, and young adults to maximize the positive potential of managed care for pediatrics. These principles include the following.

Pediatrician workforce policy statement

This policy statement reviews important trends and other factors that affect the pediatrician workforce and the provision of pediatric health care, including changes in the pediatric patient population, pediatrician workforce, and nature of pediatric practice. The effect of these changes on pediatricians and the demand for pediatric care are discussed. The American Academy of Pediatrics (AAP) concludes that there is currently a shortage of pediatric medical subspecialists in many fields, as well as a shortage of pediatric surgical specialists. In addition, the AAP believes that the current distribution of primary care pediatricians is inadequate to meet the needs of children living in rural and other underserved areas, and more primary care pediatricians will be needed in the future because of the increasing number of children who have significant chronic health problems, changes in physician work hours, and implementation of current health reform efforts that seek to improve access to comprehensive patient- and family-centered care for all children in a medical home. The AAP is committed to being an active participant in physician workforce policy development with both professional organizations and governmental bodies to ensure a pediatric perspective on health care workforce issues. The overall purpose of this statement is to summarize policy recommendations and serve as a resource for the AAP and other stakeholders as they address pediatrician workforce issues that ultimately influence the quality of pediatric health care provided to children in the United States.

Cost effectiveness analysis of elementary school-located vaccination against influenza--results from a randomized controlled trial

School-located vaccination against influenza (SLV-I) has been suggested to help meet the need for annual vaccination of large numbers of school-aged children with seasonal influenza vaccine. However, little is known about the cost and cost-effectiveness of SLV-I. We conducted a cost-analysis and a cost-effectiveness analysis based on a randomized controlled trial (RCT) of an SLV-I program implemented in Monroe County, New York during the 2009-2010 vaccination season. We hypothesized that SLV-I is more cost effective, or less-costly, compared to a conventional, office-located influenza vaccination delivery. First and second SLV-I clinics were offered in 21 intervention elementary schools (n=9027 children) with standard of care (no SLV-I) in 11 control schools (n=4534 children). The direct costs, to purchase and administer vaccines, were estimated from our RCT. The effectiveness measure, receipt of ≥1 dose of influenza vaccine, was 13.2 percentage points higher in SLV-I schools than control schools. The school costs ($9.16/dose in 2009 dollars) plus project costs ($23.00/dose) plus vendor costs excluding vaccine purchase ($19.89/dose) was higher in direct costs ($52.05/dose) than the previously reported mean/median cost [$38.23/$21.44 per dose] for providing influenza vaccination in pediatric practices. However SLV-I averted parent costs to visit medical practices ($35.08 per vaccine). Combining direct and averted costs through Monte Carlo Simulation, SLV-I costs were $19.26/dose in net costs, which is below practice-based influenza vaccination costs. The incremental cost-effectiveness ratio (ICER) was estimated to be $92.50 or $38.59 (also including averted parent costs). When additionally accounting for the costs averted by disease prevention (i.e., both reduced disease transmission to household members and reduced loss of productivity from caring for a sick child), the SLV-I model appears to be cost-saving to society, compared to "no vaccination". Our findings support the expanded implementation of SLV-I, but also the need to focus on efficient delivery to reduce direct costs.

Abortion providers' experiences with Medicaid abortion coverage policies: a qualitative multistate study

OBJECTIVE

To evaluate the implementation of state Medicaid abortion policies and the impact of these policies on abortion clients and abortion providers.

DATA SOURCE

From 2007 to 2010, in-depth interviews were conducted with representatives of 70 abortion-providing facilities in 15 states.

STUDY DESIGN

In-depth interviews focused on abortion providers' perceptions regarding Medicaid and their experiences working with Medicaid and securing reimbursement in cases that should receive federal funding: rape, incest, and life endangerment.

DATA EXTRACTION

Data were transcribed verbatim before being coded.

PRINCIPAL FINDINGS

In two study states, abortion providers reported that 97 percent of submitted claims for qualifying cases were funded. Success receiving reimbursement was attributed to streamlined electronic billing procedures, timely claims processing, and responsive Medicaid staff. Abortion providers in the other 13 states reported reimbursement for 36 percent of qualifying cases. Providers reported difficulties obtaining reimbursement due to unclear rejections of qualifying claims, complex billing procedures, lack of knowledgeable Medicaid staff with whom billing problems could be discussed, and low and slow reimbursement rates.

CONCLUSIONS

Poor state-level implementation of Medicaid coverage of abortion policies creates barriers for women seeking abortion. Efforts to ensure policies are implemented appropriately would improve women's health.

Medicaid reimbursement and the uptake of adolescent vaccines

BACKGROUND

In light of low adolescent vaccination rates, state-level policies that could improve vaccine coverage should be evaluated. Approximately 1/3 of adolescents are eligible, primarily through Medicaid enrollment, to receive vaccines from state-administered Vaccines for Children (VFC) programs. We investigated whether Medicaid reimbursement, the scope of implementation of VFC programs (i.e. limited or universal purchase), and/or presence of school-based vaccine mandates were associated with adolescent vaccination levels.

METHODS

We performed a cross-sectional analysis of state-level associations between these policies and 2009 National Immunization Survey-TEEN vaccination rates for tetanus-containing, meningococcal conjugate (MCV4), and among females only, human papillomavirus (HPV) vaccines.

RESULTS

Medicaid reimbursement was not associated with vaccine coverage rates after adjusting for presence of vaccine-related school mandates, type of VFC program, proportion of adolescents attending preventive care visits, and state-specific distribution of insurance coverage. Participation in a more expansive VFC program (universal or universal-select) was significantly associated with HPV vaccine coverage, but not tetanus-containing vaccine or MCV4, among states that had mandates for any vaccines.

CONCLUSIONS

Our results suggest that, contrary to what has been shown for childhood vaccines, raising Medicaid reimbursement rates may not improve adolescent vaccine utilization. Instead, other policy changes may be more effective, such as expansion of VFC programs into universal purchase programs, further implementation of school-based vaccine mandates and efforts to raise preventive care visits among adolescents.

How to improve influenza vaccination rates in the U.S

Annual epidemics of seasonal influenza occur during autumn and winter in temperate regions and have imposed substantial public health and economic burdens. At the global level, these epidemics cause about 3-5 million severe cases of illness and about 0.25-0.5 million deaths each year. Although annual vaccination is the most effective way to prevent the disease and its severe outcomes, influenza vaccination coverage rates have been at suboptimal levels in many countries. For instance, the coverage rates among the elderly in 20 developed nations in 2008 ranged from 21% to 78% (median 65%). In the U.S., influenza vaccination levels among elderly population appeared to reach a "plateau" of about 70% after the late 1990s, and levels among child populations have remained at less than 50%. In addition, disparities in the coverage rates across subpopulations within a country present another important public health issue. New approaches are needed for countries striving both to improve their overall coverage rates and to eliminate disparities.

This review article aims to describe a broad conceptual framework of vaccination, and to illustrate four potential determinants of influenza vaccination based on empirical analyses of U.S. nationally representative populations. These determinants include the ongoing influenza epidemic level, mass media reporting on influenza-related topics, reimbursement rate for providers to administer influenza vaccination, and vaccine supply. It additionally proposes specific policy implications, derived from these empirical analyses, to improve the influenza vaccination coverage rate and associated disparities in the U.S., which could be generalizable to other countries.

Financial impact to providers using pediatric combination vaccines

OBJECTIVE

To understand the financial impact to providers for using a combination vaccine (Pediarix [GlaxoSmithKline Biologicals, King of Prussia, PA]) versus its equivalent component vaccines for children aged 1 year or younger.

METHODS

Using a subscription remittance billing service offered to private-practice office-based physicians, we analyzed charge and payment information submitted by providers to insurance payers from June 2007 through July 2009. We analyzed provider and payer characteristics, payer comments, and the ratio of vaccine product to immunization administration (IA) codes and computed total charges and payments to providers for both arms of the study.

RESULTS

Most providers in our data set were pediatricians (74%), and most payers were commercial (75%), primarily managed care. The ratio of the number of vaccine products to the number of IAs was 1:1 in the majority of the claims. Twenty percent of claims were paid with no adjustment by the payer, whereas 76% of the claims were adjusted for charges that exceeded the contract arrangement or the fee schedule. Providers received $23 less from commercial payers and $13 less from Medicaid for the use of Pediarix compared with the equivalent component vaccines. The mean commercial payment was greater for age-specific Current Procedural Terminology IA codes 90465 and 90466 than for non-age-specific codes 90471 and 90472, whereas the reverse was true for Medicaid.

CONCLUSIONS

Providers who administer vaccines to children face a reduction in payment when choosing to provide combination vaccines. The new IA codes should be monitored for correction of financial barriers to the use of combination vaccines.

Influenza vaccination coverage among high-risk groups in 11 European countries

BACKGROUND

National vaccination coverage rates for individuals at increased risk of influenza-related complications represent a useful public health indicator of preparedness. We compared European countries regarding (i) vaccination coverage among high-risk groups and (ii) the likelihood that high-risk individuals reported influenza vaccination compared with those at lower risk.

METHODS

We used data from the Survey of Health, Ageing and Retirement in Europe (SHARE) collected in 2004-05. Adults aged ≥ 50 years from 11 countries provided self-reports of an influenza vaccination in the previous year (n = 16,913). We defined four high-risk groups (age ≥ 65 years, presence of vascular disease, chronic lung disease or diabetes) and calculated vaccination coverage with 95% confidence intervals for each country. Country-specific multivariable logistic regression was used to estimate odds ratios (ORs) for membership in a high-risk group and vaccination.

RESULTS

The Netherlands had the highest influenza vaccination coverage in high-risk groups (≥ 75% in any group) while Greece had the lowest (<27% in any group). Older age was positively associated with report of vaccination in all countries, but the strength of this association varied from an OR of <2 (Germany) to >13 (The Netherlands). The ORs for the chronic disease groups was ≥ 4 for The Netherlands and were considerably lower (and often not statistically significant) for the other countries.

CONCLUSION

Influenza vaccination coverage among high-risk groups varies considerably between European countries. Our findings highlight potential opportunities for reducing influenza-related complications through support for vaccination programs that target high-risk individuals more effectively.