Faruque Ahmed1, Virginia Paine2, Fan Zhang1, Edith Gary1, Peng-Jun Lu1 Evaluation of a Legislatively-Mandated Influenza Vaccination Program for Adults in Rhode Island National Immunization Conference April 1, 2009 Faruque Ahmed1, Virginia Paine2, Fan Zhang1, Edith Gary1, Peng-Jun Lu1 1Centers for Disease Control and Prevention 2Rhode Island Department of Health

Outline Background Program description Resources Provider enrollment and training Vaccine ordering and shipment Provider reporting requirements Evaluation of 1st year of program Process Outcome

Population: 1.1 million (80% NH White, 11% Hispanic, 6% Black) Smallest state by area, 8th smallest state by population Health dept located in Providence. Physicians in Providence and other border areas also see pts from Mass. And Conn. Population: 1.1 million (80% NH White, 11% Hispanic, 6% Black) Area: 1214 sq miles (length: 48 miles, width: 37 miles)

Background Physicians unhappy with the influenza vaccine supply problem for several years Rhode Island state law passed in July 2006 Dept of Health to purchase and equitably distribute influenza vaccine for adults Cost to be underwritten by insurers In response, the Dept of Health developed the Immunize for Life adult influenza vaccination program Based on provider goodwill with the state’s handling of VFC vaccines, legislation was passed for the adult program in December 2006

Program Resources, Year 1 Rhode Island Dept of Health staff 2.7 FTEs Contractors Web-based enrollment and vaccine ordering system Influenza vaccine distribution $2.7 million from insurers, Medicare and Medicaid 258,000 doses of vaccine for 2007-08 season

Program Description Adult health care providers Receive influenza vaccine free of charge Bill insurers and Medicare for vaccine administration costs Persons eligible to receive influenza vaccination through the program* At least 19 years of age Live or work in Rhode Island Have health insurance RI has small amount of federal funding for vaccinating uninsured adults. *Uninsured adults to be referred to a provider who is part of the approved community network for the uninsured

Immunization Start Date October 17, 2007 Ensure that there would a adequate supply of vaccine for each practice/facility Common start date levels the playing field Also applies to mass immunizers and non-participating providers Supported by Adult Flu Advisory Group, Pediatric Immunization Advisory Group, Primary Care Physician Advisory Committee, Adult Immunization Coalition, and health insurers PCPAC: Primary care physician advisory committee, OSAIC: Ocean state adult immunization coalition. Start date also applies to mass immunizers and non-participating providers. In previous yrs, physicians were not happy that mass immunizers were vaccinating before they received their vaccine supply.

Promotional Materials Distributed to participating adult care providers to inform the public Flu vaccination campaign start date Continued vaccination opportunities throughout the flu season

Provider Enrollment Using a database purchased from Health Market Science Identified 810 adult health care provider sites, regardless of specialty State mailed information about the program with enrollment instructions 51% (412/810) of provider sites enrolled

Participating Providers Number Private practices 249 Nursing homes 72 Health centers 32 Urgent care facilities 22 Hospitals 17 Businesses 8 Mass immunizers 7 State agencies 2 Other 3

Provider Training State staff conducted 24 training sessions at locations across the state Program policies and procedures Vaccine storage and handling A representative from each practice or facility required to attend a training session

Vaccine Ordering by Providers Order vaccines using State’s website Non-use/waste margin of 10% allowed >10% non-use/waste will require payment to the State of $11.80/dose State will facilitate transfer of leftover vaccines to other practices/facilities

Vaccine Shipment 400 doses or 40% of total order, whichever is greater, by the week of October 1 Balance shipped by end of October Full shipment if total order less than 400 doses

Provider Reporting Requirements Monthly refrigerator temperature log Monthly inventory form Doses received Doses given by age group Doses spoiled Doses transferred Annual vaccine tally form Persons vaccinated, by health plan Vaccines administered to ineligible persons

Evaluation

Evaluation Key informant interviews Provider survey BRFSS* Response rate = 35% (144/412) BRFSS* Rhode Island vaccination rate U.S. vaccination rate *Flu vaccination during the past 12 months

Key Informant Interviews Selected Likes Because of the start date We were all on an even playing field Knew when vaccine would be delivered and when vaccinations would start They removed a lot of the uncertainty related to vaccine prices and supply Don’t have to put money out for vaccines upfront Particularly impressed with how well the program went considering it was the first year Program staff were always available, helpful, and knowledgeable and responded in a very timely manner to any questions and concerns

Key Informant Interviews Selected Dislikes Inability to give vaccine before Oct 17 led to missed opportunities for giving flu shots Changes to the program as it evolved led to a great deal of confusion in the trainings, especially for participants who attended the initial trainings Mass immunizers Had to add extra clinics and had trouble staffing them because the delayed start date of Oct 17 created a rush to get the vaccine Would have liked all vaccines in one shipment for planning purposes

Key Informant Interviews Paperwork and Billing Tracking shots by age group and insurance type was difficult and tedious Paperwork was not a problem for providers who already had strong internal tracking systems, or once they developed a process for tracking Billing confusing Changes in billing to reflect reimbursement for vaccine administration only Each insurer wanted claims filed differently

PROVIDER SURVEY Enrollment and Training Yes or Agree (%) Online enrollment process was user-friendly 93 Satisfactory and timely assistance with enrollment 96 Choice of convenient training session times and locations 90 Received adequate information about the program 97

Vaccine Ordering and Shipment Yes or Agree (%) Received the amount of vaccine ordered 97 If requested more vaccine later, received it 89 Initial vaccine shipment before the October 17 start date 87 Distributor clearly communicated vaccine delivery date

Start Date and Reporting Requirements Yes or Agree (%) Satisfied with the October 17 start date 80 Paperwork was reasonable 71

Claims and Payments Yes or Agree (%) Provided with information on how to file claims 78 Difficulties in receiving reimbursement from insurers* 30 Had to pay for unused or spoiled vaccine 17 *For vaccine administration

Overall Assessment Yes or Agree (%) Plan to enroll for the 2008-09 influenza season 98 Would encourage other providers to enroll 95 Overall satisfaction 94

Factors Associated with Overall Satisfaction Choice of convenient training session times and locations Agree Disagree 124 14 96* 79 Influenza program paperwork was reasonable 97 40 98* 83 *P < 0.05 (also significant in multivariate logistic regression model)

Factors Not Associated with Overall Satisfaction Factors include: Satisfaction with the Oct 17 start date Provided with info on how to file claims Difficulties in receiving reimbursement Had to pay for unused or spoiled vaccine

BRFSS Influenza Vaccination Rate (%) Age 65 and older (Preliminary) 2006* (Pre) 2007† (Post) Rhode Island 80.7 83.2 U.S. 67.5 70.3 *BRFSS interviews during December 2006 †BRFSS interviews during December 2007

Conclusions High satisfaction with Enrollment and training Vaccine ordering and shipment Lower satisfaction with Paperwork Claims for vaccine administration High overall satisfaction with program

Disclosure Information The findings and conclusions are those of the authors and do not necessarily represent the views of the CDC

Questions? Virginia Paine Rhode Island Department of Health Virginia.Paine@health.ri.gov Faruque Ahmed Centers for Disease Control and Prevention Fahmed@cdc.gov