1. Emerging Gaps in Financing for New Vaccines
Tracy Lieu, MD, MPH
for Grace Lee, MD, MPH
Center for Child Health Care Studies, Dept of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School

2. Plan Background Vaccine implementation by states and cities
Barriers to implementation
Strategies for financing
In Phase 2, which was the national survey, we sent written surveys and conducted 1 hour semi-structured phone interviews with those who were not previously interviewed. This took place from Jan to Jun Surveys and interviews included questions about the….
Interviews were audiotaped, transcribed, and coded

3. Number of Vaccines in the Routine Childhood & Adolescent Schedule
1985
1995
2006
Measles
Rubella
Mumps
Diphtheria
Tetanus
Pertussis
Polio
Measles
Rubella
Mumps
Diphtheria
Tetanus
Pertussis
Polio
Hib
HepB
Varicella
Measles
Rubella
Mumps
Diphtheria
Tetanus
Pertussis
Polio
Hib
HepB
Varicella
Pneumococcal disease
Influenza
Meningococcal disease
HepA
Rotavirus
HPV* 7 10 16
* Provisional ACIP recommendation, not yet published

4. Federal Contract Prices for Vaccines Routinely Recommended for Children and Adolescents
 $1,200
$900
$155
$45

5. VFC and Section 317 Vaccine Funding to Immunization Programs

6. State and City Immunization Programs
Types of funding:
VFC
317
State—variable (0% to ~45%)
Policies for implementation depend on available funding

7. Childhood Vaccine Doses by Funding Source, 2005
Source: Vaccine manufacturers Biologic Surveillance Data 2005
Note: Does not include influenza vaccine

8. State Vaccine Supply Policies 1994 - 2000
VFC-eligible
Under-insured
Insured
Universal
All
VFC enhanced
None
VFC only
None*
* Unless 317 or state funds available

9. State Vaccine Supply Policies 2000 – present (post-pneumo)
VFC-eligible
Under-insured
Insured
Universal
All
Universal select
Some
VFC enhanced
None
VFC enhanced select
VFC only

11. Study of Implementation and Financing of New Vaccines Aims
Describe states’ current policies for new vaccines
Identify barriers to implementation
Describe strategies to address gaps in financing

12. Contributors AIM CDC MA Immunization Program
Claire Hannan
CDC
Jeanne Santoli
Lance Rodewald
Mark Messonnier
MA Immunization Program
Susan Lett
Immunization Program Managers
Harvard
Grace Lee
Tracy Lieu
Jim Sabin
Donna Rusinak
Charlene Gay

13. Methods State & city immunization program managers Qualitative phase
1-hour interviews with 9 states, Nov – Dec 2005
National survey
Written surveys and 1-hour interviews with all program managers, Jan – Jun 2006

14. Topics Overall vaccine supply policy
Status of implementation of newest vaccines
Barriers to implementation
Strategies to address gaps in financing

15. Results Participation Experience in position 49 of 53 program managers
Response rate 89%
Experience in position
Median 5 years
Range 6 months – 27 years

16. Vaccine Supply Policy - 2006

17. Changes in Vaccine Policy
Universal
2 states
Universal Select
VFC enhanced
1 state
5 states
VFC enhanced select
3 states
VFC only

18. Implementation in VFC-eligible Children in 49 states/cities

19. Implementation in Underinsured Children in 49 states/cities

20. Where Underinsured Children May Seek Vaccination
Federally-qualified health centers or rural health centers (not enough)
Private providers
Public clinics

21. Underinsured Children Not Covered via Private Providers

22. Underinsured Children Not Covered in Public Clinics

23. Barriers to Vaccine Implementation
Funding
Supply
Other issues

24. Funding Gaps as a Barrier to Implementation in the Underinsured
317
State
* Among states not implementing in all underinsured

25. Supply Issues as a Barrier to Implementation in the Underinsured
* Among states not implementing in all underinsured

26. Other Reasons for Delay
Low demand for hepatitis A
Need to use up existing doses of Td
Equity
Delay until funding secured for entire population

27. Other Reasons for Delay
Federal allocation and need to build up supply
Lack of published recommendations
Need to modify registry

28. Strategies to Address Limitations in Financing
Since funding was the major barrier for programs in delivering vaccine to underinsured, we asked program managers about strategies they used to address limitations in vaccine financing

29. Strategies to Expand Vaccine Funding
Strategy
# of states
Annual state appropriation 25
One-time state appropriation 18
Expanded designations of FQHCs / RHCs 14
SCHIP 11

30. Strategies to Expand Vaccine Funding
Strategy
# of states
Annual health plan appropriation 4
One-time health plan appropriation 3
Other sources: Title 20, tobacco funds,
MCH block grants, Medicaid match, Title V

31. Expanded Designations of FQHCs or RHCs (14 states)
All private and public VFC providers (1)
All public VFC providers (3)
Some public VFC providers (9)
Some public VFC providers through state funding (1)

32. Other Strategies # of states Strategy
Prioritized subgroups (e.g., Menactra) 31
Used state/federal funds to offset each other 28
Limited provider vaccine choice 27

33. Other Strategies, cont. Strategy # of states
Asked providers to pay for loss of vaccine 19
Negotiated state contract with manufacturer 11
Decreased adult vaccine purchase
9 (of 32)
Billed insurance companies for patients vaccinated at public clinics

34. Conclusions
Underinsured children face growing gaps in vaccine financing
Many states have had to change overall supply policies

35. Conclusions Expansion of access for underinsured children is needed
Immunization program managers have developed a variety of strategies for funding

36. to immunization program managers!
Thank You
to immunization program managers!

39. State Policies State health insurance mandate Provider vaccine choice
Yes-ACIP/AAP recs 35%
Yes-no requirement 17%
No %
Provider vaccine choice
Yes-all vaccines 54%
Yes-some vaccines 20%
No %

40. Number of Vaccines in the Routine Childhood & Adolescent Schedule