1. Immunization Programs’ Challenges and Opportunities: We Are In This Together AIM Program Managers Meeting January 20, 2010 Atlanta, GA Lance E. Rodewald, MD Director, Immunization Services Division National Center for Immunization and Respiratory Diseases, CDC

2. Working Together is Essential When the Job is Tough

3. Topics  Performance  Opportunities and challenges  Resources  Planning

4. PERFORMANCE Heterogeneously high coverage for young children Room to improve for teens and influenza

5. Adolescent Immunization, U.S., 2006 - 2008 Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv

6. Adolescent Immunization by Race and Ethnicity, 2008 (1) Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv

7. Teen NIS Results by Race and Ethnicity, 2008 (2) Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv

8. Adolescent Immunization and Federal Poverty Level, 2008 Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv

9. Dt/Dtap; NIS-Teen – 2008 State-Level Coverage Rates Source: MMWR 2009;58:997 U.S. National Average: Blue

10. Dtap; NIS-Teen – 2008 State-Level Coverage Rates Source: MMWR 2009;58:997 U.S. National Average: Blue

11. MCV4; NIS-Teen – 2008 State-Level Coverage Rates Source: MMWR 2009;58:997 U.S. National Average: Blue

12. 1-Dose HPV4; NIS-Teen – 2008 State-Level Coverage Rates Source: MMWR 2009;58:997 U.S. National Average: Blue

13. Increasing Vaccine-Specific Coverage Rates Among Preschool-Aged Children † DTP(3+) is not a Healthy People 2010 objective. DTaP(4) is used to assess Healthy People 2010 objectives. Note: Children in the USIS and NHIS were 24-35 months of age. Children in the NIS were 19-35 months of age. Source: USIS (1967-1985), NHIS (1991-1993) CDC, NCHS, and NIS (1994-2006), CDC, NIP and NCHS; No data from 1986-1990 due to cancellation of USIS because of budget reductions. DTP / DTaP(3+) † MMR(1+) Hib (3+) 2010 Target Hep B (3+) Polio (3+) Varicella (1+) PCV 7 (3+)

14. 431331; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

15. 3 Hep B; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

16. Hep B Birth Dose; NIS – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

17. 2 Hep A; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

18. 1 MMR; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

19. Vaccination Coverage Levels at 19-35 Months of Age by Race and Ethnicity, 1995 – 2008; MMR 1+ Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv

20. Omer S, et al. NEJM 2009;360:1981-1988

21. Measles Cases Reported to CDC/NCIRD January 1 to July 11, 2008 (N= 132) San Diego, CA Outbreak N=12 (CA =11, HI =1) Source=Switzerland, D5 Jan 25-Feb 16 Missaukee County, MI Outbreak, N=4 Source=Unknown, D5 Feb 29-Apr 8 Pima County, AZ Outbreak N=18 Source=Switzerland, D5 Feb 13-May 2 Los Angeles, CA N=2 Source=Unknown Mar 23-Apr 16 Fairfax, VA N=1 Source=India Feb 25 Milwaukee County, WI Outbreak, N=6 Source=China-H1 Mar 19-Apr 25 Nassau County, NY N=1, Source=Israel Apr 4 New York City, NY N=27 Sources: Israel (1) Belgium (2) D4 Italy (1) Other Import- associated (10) Source Unknown (13) Jan 18-Jun 10 Honolulu, HI N=4 Sources: Italy (2) China (1) Philippines (1) Feb 5-May 22 Pittsburgh, PA N=1 Source=Unknown Apr 12 Chicago, IL N=1 Source=Switzerland Apr 17 Grant County, WA Outbreak N=19 Source= Japan Apr 12 - May 30 Vernon County, WI N=1 Source=Germany Apr 25 Scott County, AR N=2 Source= Unknown Feb 12-Feb 22 San Francisco, CA N=2, Sources: India (1), Italy (1) Apr 18, Jun 22 D.C. N=1 Source Unknown Apr 20 Chaves Co, NM N=1, Unknown Mar 17 Baton Rouge, LA N=1, Russia May 14 Du Page Co, I L Outbreak N=27 Source=Italy, D4 May 15-Jun 25 Fulton Co, GA N=1 Pakistan May 14 Cass Co, MO N=1 Source Unknown Apr 7

23. 3 Hib; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

24. Coverage Measurement for Hib Vaccine in Face of the Shortage  Prior to 2010, NIS did not distinguish among Hib vaccines  Practicing correctly during shortage could result in being UTD or not UTD depending on the vaccine – In 2008 NIS, 8% of children vaccinated in shortage months  Dip in coverage seen will increase, but differently for states depending on their prior Hib vaccine selection  NIS changed to capture specific product starting in 2010  If NIS change does not allow correct determination, will have to have policy decision on coverage measurement for Hib

25. RATIONALE FOR REACHING MORE CHILDREN AND ADULTS Immunization Program Perspective

27. Foundation for the ARRA-Immunization Spend Plan: Section 317 Report to Congress   Annual estimate for “optimum State and local operations funding, as well as CDC operations … to conduct and support childhood, adolescent and adult [immunization] programs.”   Beginning in FY 2007 and each subsequent fiscal year   FY 09 – – Appropriation $557.4 million – – Estimated need $1,315.6 million (vaccine purchase and operations) – – Funding gap: $758.2 million

28. Vaccine   Programs blend entitlement vaccine funding with discretionary vaccine funding – – Only entitlement funding grows with need – – Need has increased markedly since 2000   Growth in need raises expectations on discretionary vaccine funding, federal and state   Consequences of unmet expectations is significant – – Delayed introduction of new vaccines – – Incomplete implementation of vaccines – – Decisions about vaccine implementation varies by state

29. Grantees Provision of Vaccines to Underinsured Children, 2006 (N=49) Source: Grace Lee et al; Harvard University

30. Implementation of MCV4

31. Lancet 2008 March 15; 371:881-882

32. Operations   Vaccine use has increased markedly since 2000, but operations funding has grown much less – – Fewer dollars per dose to support vaccination efforts – – Vaccination environment is more difficult   State budget declines are shrinking public health programs   Local public health is experiencing reductions in workforce due to budget cuts – – Loss of capacity – – Loss of expertise

33. Opportunity Afforded by Reaching More Children and Adolescents Project   States determine vaccination projects – – Addresses variation in vaccine implementation by state – – Best fit with local health system environment   Many different projects proposed – – Tdap vaccination of newborn contacts – – Health care workers and influenza or Tdap – – Hepatitis B vaccine in STD clinics   Allows states to make progress against VPDs

34. Risks and Challenges   Challenges – – One-time funding – – Starting and stopping program activities   Risks – – Not using all of the available funding – – H1N1 activities competing with ARRA-317 activities at state level

35. Outcomes Desired   Direct public health benefit   Demonstration that Section 317 has capacity to do more and make good on the funding investment   Increased experience at state level for new vaccination projects

36. IMPROVING REIMBURSEMENT IN PUBLIC HEALTH DEPARTMENT CLINICS Description and Section 317 Perspective Rationale

37. A Basic Question  Insurance plans pay for immunizations at primary care provider offices  Some children or adults will present to the health department for vaccination for many reasons – Provider does not offer specific vaccine – Patient does not have provider – Convenience of health department – Inability to pay for office visit  Should the insurance plan covering vaccination services be billed for services rendered in health department clinics?

38. Rationales for “Yes” Answer  Public health should be paid for work performed, just as anyone else should (equity)  Parents and employers pay the health plan for vaccinations; health plans should not be subsidized with government money when they have private money for same service (common sense)  Paying for those already covered privately limits what programs can do with their scarce public resources (stewardship)

39. Billing Practices  One systematic study from 2001 on health department billing – 94% bill Medicaid for their assigned pts – 64% bill Medicaid for referred pts – 31% bill private insurance Santoli J, et al. AJPM 2001; ;20(4):266–271)

41. How Did This Situation Happen? – History and Barriers  Desire to never turn a child away (no missed opportunities)  Vaccines used to cost much less  Health department clinics generally not set up at “in-network” providers to bill private health insurance – there are barriers to participation

42. THE OREGON EXPERIENCE

43. Why?  Increased cost to vaccinate a child from new vaccines  Pressure on Section 317 as a resource for vaccinating (mismatch between VFC and Section 317 funding)  Oregon had to become “less inclusive” in their statewide immunization program

44. Oregon’s Approach  Study local health department payor mix  Strategic planning with all stakeholders with data as basic input  Recommendation of stakeholders to no longer support immunization of well-insured individuals  Survey of billing practices  Consensus process to implement plan

45. Oregon’s Results: Increased Revenue and Sparing of Section 317 Funding

48. Public Health Impact

50. 14 Grantees Funded Through ARRA-317 Innovative Projects to Improve Reimbursement in Public Health Department Clinics NYC

51. Expected Outcomes  Executable plans  Revenue stream to sustain public health capacity  Lessons for further promotion  Long-term stabilizing force for shared public/private immunization effort

52. FUNDING STATUS Operations and Vaccine

53. Immunization Program Operations Funding * : FY06 – FY10 * Shown in millions of dollars; includes Section 317 and VFC

54. Immunization Program Operations Funding * : FY06 – FY10 FY06FY07FY08FY09FY10 MinFY10 Max New ** 255.1262.9257.4277.4276.7280.4 Carryover 23.117.75.019.18.1 Pan flu 15.415.714.015.7 ARRA 79.7 Total 278.2280.6277.9312.2378.4383.8 * Shown in millions of dollars; includes Section 317 and VFC ** Includes DA and travel

55. VFC Non-Vaccine Funding * : FY09 – FY10 * Shown in millions of dollars

56. VFC Non-Vaccine Funding * : FY09 – FY10 FY09FY10 OPS23.726.4 Ordering8.88.3 Distribution0.50.6 AFIX37.738.6 DA Other0.60.2 DA Personnel2.02.4 Carryover0.40.3 Total73.676.8 * Shown in millions of dollars

57. Vaccine Funding to Grantees: FY06 – FY10

58. Immunization Program Vaccine Funding * : FY06 – FY10 FY06FY07FY08FY09FY10 VFC 1,6812,4232,4342,9783,285 Section 317 225244255256254 ARRA-317 44124 Total 1,9062,6672,6893,2783,662 * Shown in millions of dollars; includes Section 317 and VFC

59. Program Funding Observations  Unprecedented level of resources, vaccine and operations  Current resources are part-way to CDC’s professional judgment level  Using one-time funding is a challenge, but one worth meeting

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61. LOOKING FORWARD

62. Using Your Enhanced Influenza Programs  H1N1 provided unprecedented expansion of influenza vaccination capacity  Strong interest in using new capacity for seasonal vaccination effort, without missing the 2010 vaccination season  School-located vaccination, obstetricians, increased pediatrician interest, community vaccinators, etc.

63. Making the Most of ARRA-317  ARRA challenges – One-time funding – H1N1 opportunities costs  Not using funding weakens argument that Section 317 is underfunded  Principles and policy for flexibility, grantee priority, and using the funding prior to end of FY2010  Policy implementation involves collaboration and sharing across programs: working together

66. Pediatrics 2009;124:S571-S572

67. VFC and Delegation of Authority for Underinsured Children  VFC legislative proposal has not been introduced in Congress  Delegation of VFC authority from FQHC/RHCs to other VFC providers: – Is occurring (CDC is aware) – Is being honored (CDC allows VOFA to include delegated sites) – Is not currently being provided guidance by CDC  Programmatic options for delegation of VFC authority are being developed within HHS

68. VTrckS Implementation  Business transformation at CDC – Purchase to Pay – Order to Distribute – Real-time data systems  Capacity transformation in programs – Retirement of VACMAN – Orders can be placed by providers – IIS interfaces supported  Time line is aggressive in FY2010

69. ARRA-317 and ARRA-HITECH IIS Projects  Limited competition cooperative agreements to increase interoperability between EMRs and IIS – Addresses persistent IIS challenge of duplicate data entry – Strong move toward real standards – Two-year project period  Exportable, usable ACIP-standard algorithms for IIS – Minimizes annual reprogramming

70. Conclusions (1)  Immunization programs are high-performance public health programs  Support for immunization programs is very strong – Coalitions of public and private sectors are working hard to support your efforts – Resources are improving at a judicious pace  Many opportunities exist to protect more people from vaccine preventable diseases

71. Conclusions (2)  2010 presents fundamental challenges – ARRA-317 represents a critically important opportunity that cannot be missed – Capitalize on your H1N1 successes for seasonal influenza – Prepare for VTrckS implementation to move forward  We are all in this together to fulfill the potential of vaccines to prevent suffering from preventable diseases

72. Let’s Talk About All This

73. EXTRA SLIDES

74. Adolescent Immunization, Progress Toward HP2010 Objectives VaccineHP 2010 Objective2008 Teen NIS results MMR, 2+90%87.9% Hep B, 3+90%89.3% Td/Tdap90%72.2% Varicella vaccine or disease 90%92.7% Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv

75. Adolescent Immunization, Progress Toward HP2010 Objectives VaccineHP 2010 Objective2008 Teen NIS results MMR, 2+90%87.9% Hep B, 3+90%89.3% Td/Tdap90%72.2% Varicella vaccine or disease 90%92.7% Source: National Immunization Survey: http://www.cdc.gov/vaccines/stats-surv

76. 3-Dose HPV4; NIS-Teen – 2008 State-Level Coverage Rates * Source: MMWR 2009;58:997 * States with cell sizes too small are not included U.S. National Average: Blue

77. 4 DTaP; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

78. 3 Polio; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

79. 1 Varicella; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

80. 4 PCV7; NIS 19 to 35 mo. – 2008 State-Level Coverage Rates Source: MMWR 2009;58:921 U.S. National Average: Blue

81. Oregon’s Procedure