1. Implementing Vaccine Billing – Oregon’s Experiment
Successful!
Lorraine Duncan, Immunization Program Manager
Oregon Public Health, Immunizations

2. Preserving 317 Funds
Oregon Local Health Departments (LHD) now bill health plans or families for the cost of vaccine and administration for well-insured clients.
Immunization Program then bills LHDs for these “billable” doses (not admin. fees)
A long process
A great outcome
I’d like to talk to you today about how Oregon decided to preserve our 317 vaccine funds by collecting money from health plans when fully insured folks get their vaccines through our public clinic system.
It took us several years to implement, but as you’ll see, the outcome was well worth it.

3. What, and why?
Policy Board said: No more public dollars on well-insured because of:
“Flat” 317 $$$
Two tiered system
Evidence of well-insured seeking immunizations at public clinics.
“Medical Home” teeter totter
No adult vaccines $$$.
The most basic – we knew that 317 funds were flat – or shrinking.
We knew there were vaccines we couldn’t afford to add with 317, and we knew more were on the way.
We’d been wanting to put more energy into adult immunization services.
And we knew that some well-insured folks were being served with 317 funded vaccines at our public clinics. As much as we strive to keep folks in private medical homes, the reality is that these people end up using public health departments.
We had been billing both private and public sites for wasted/expired vaccine for many years, so we knew we had the business systems available if we wanted to head down the course of billing.

4. The Big Idea!
What would happen if Oregon stopped underwriting privately-funded health plans with taxpayer-funded vaccines?
We came up with an idea. Stop spending precious 317 dollars to fund vaccination for the well-insured population seeking services at public clinics. Instead, save those dollars to use on routine childhood and specific adult vaccines.

5. Next, we began the talking….
Began early discussions
Internal
LHD Immunization Coordinators
IPAT
Conference of Local Health Officials
These early discussions were a great example of cultural change – much angst, much trepidation, much resistance.

6. And got consensus to move forward…
Survey
Assessed each LHD capacity to bill. Lots of individual technical assistance.
Several counties had extensive experience billing for services – immunization and other. They provided much support and technical assistance.
“317 Calls” –Numerous conference calls with all 35 local health departments over the course of one year.
Public clinics worked hard with their private providers to keep/funnel the well-insured there.
After nearly a year of discussions, we received permission to move forward. Through paper surveys and many conference calls with all LHD immunization coordinators, we gathered the info we needed to come up with a plan. Quite a few LHDs used the change to increase their efforts with private medical providers to get the well-insured served privately, not in public clinics.

7. A good place to start Refine data with expanded Eligibility Codes:
Went from five codes (M, N, A, U, I) to 11 codes:
We strategized internally and with our LHD partners to capture enough information to be able to bill fully insured folks, and to begin a process of changing our eligibility codes. We knew we wanted to capture info on the well-insured, but we also wanted to capture more subtle information: For instance, the “c” code was designed so that some day we can go to our health plans and let them know exactly how much public tax money is being spent on vaccines because their insureds cannot afford co-pays/deductibles.

8. Then Practice…and Begin!
Training Plan:
Dec 2001 Imm Program * Design & Distribute Plan
Jan-May 2002 Imm Program * On site training at all LHDs
April 2002 More Training *Annual LHD Immi Conference
June 2002 Imm Program & LHDs * Implement New Codes
in all data systems
Dec 2002 Imm Program * Issue first of two “fake” quarterly
bills to LHDs
Jan 2003 LHDs * Begin charging plans/families
June 2003 Imm Program * Issue first real quarterly bills
Once the codes were finalized, we set forth to implement the new system. The key here was to implement for six months with “FAKE” bills – we asked our public clinics to begin using the new codes without actually collecting funds. Then, each of those two quarterly bills were scrutinized by their staff and state staff. Once the kinks were worked out, the real-deal began.

10. What the process looks like:
We give clinics a LONG time to assure they can change eligibility codes when necessary. For instance, if they code a client’s shots as “R” for unknown, but discover in fact the shots were billable, they can change the code before we gather data and generate a bill.

11. Outcomes? 3 Quarters Only…MCV4
While we knew there were well-insured folks seeking care at our public clinics, we did not really know the extent until implementation.

12. Revenue by Quarter
Probably difficult to view this slide, but we included it so you can review the quarter-by-quarter results since implementation. Third quarter is always largest, representing the school exclusion surge.

13. What are we doing with the $$$?
Routine 317 coverage added for:
Hepatitis A for children
Hepatitis A & B for many high-risk adults.
Tdap for adolescents and adults
Special Pilot Projects:
PPV23 & Flu, hospital standing orders
Hepatitis B, hospital birth dose
Hep A & B Planned Parenthood
Now, let’s talk a bit about what we’ve done with the savings. We take the 317 savings and have expanded both routine coverage (like hepatitis a for 317 eligible children), and a few exciting special pilot projects (ppv23 standing orders, and birth dose standing orders). If you have questions about those projects, please let me know.

14. A little bit of the technical:
We bill in arrears.
Revenue is spent on vaccines we need to replenish our inventory – not a vaccine for vaccine replacement process.
We make those purchases outside of the CDC vaccine contracts.
A few technical details about how the new system works.

15. Next? Continue striving for medical home models;
Begin working with health plans on a model 1st dollar coverage policy (not law);
Face the challenges of continued stagnation in 317 funding;
New vaccines coming Maintain the two-tiered system?
As with all areas of immunization programming and policy development, many challenges remain… Help assure medical home access, enhance our relationships with the health plans to increase their coverage of immunization related services, work with legislative and policy making bodies to enhance funding and opportunities, and deal with the costs of pipeline vaccines.

16. Questions?