1. 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

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

3. 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)

4. 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

5. 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 season

6. 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

7. 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.

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Evaluation

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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

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

25. 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)

26. 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

27. 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

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

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

30. Questions? Virginia Paine Rhode Island Department of Health
Faruque Ahmed
Centers for Disease Control and Prevention