The view from state and local programs

Abstract

We are pleased to comment on this supplement to the American Journal of Preventive Medicine devoted to the findings and recommendations of the Institute of Medicine (IOM) Committee on Immunization Finance Policies and Practices, and on the research supporting them. Our challenge, as participants in the Committee’s fact-finding activities, was to describe adequately the impact of the dramatic funding fluctuations experienced by immunization programs over the past decade, during which immunization programs were affected not only by funding instability, but also by the rapidly changing health care delivery system. This period also saw the emergence of managed care, implementation of the Vaccines for Children (VFC) program, and the start-up of the State Children’s Health Insurance Program (SCHIP). Immunization programs were further challenged by the introduction of several new vaccines and the move to broaden efforts to immunize throughout the life span. The IOM’s conclusions and recommendations in Calling the Shots1are on target: Stable, equitable, and increased funding for public health infrastructure is necessary to achieve nondisparate child and adult immunization protection and to perform the public health functions of assessment, assurance, and policy development in today’s evolving health care environment. The articles in this issue by Johnson et al.2 and Miller3 provide insight into our complicated national funding structure and make the case for predictable and sustained federal support for immunization. As participants in the case study of Los Angeles and San Diego counties, we attest that Fairbrother et al.4 identified key factors that affect a jurisdiction’s success in improving immunization coverage. These include the proportion of the population living below poverty level; the availability of affordable vaccines from the medical home; and the ability of managed care, especially Medicaid managed care, to ensure timely delivery of vaccines; and the development of community partnerships to outreach to diverse populations. With about 80% of childhood vaccines now being given in the private sector, public health’s role has shifted, which is well described in the article as a change from service delivery to oversight and monitoring; that is, a transition for health departments from “rowing” to “steering.” In our new role we need to find ways to ensure that vaccine delivery in the complex private sector is accessible, with reduced out-of-pocket expense, and given according to the latest clinical recommendations. Fairbrother et al.4 also highlight the important issues of perceived inadequate capitation rates within managed care, and the particular problem faced by states with freestanding SCHIPs (those that are not Medicaid expansions), in which children are not eligible for VFC vaccines. Finally, we concur with the authors’ findings that, even with the shift to private vaccine delivery, public health must continue to maintain a true immunization “safety net” in the community. In the literature and in our new assurance roles, we have identified practice management immunization strategies that work, such as patient appointment reminders; patient recall and tracking; immunization status checks at every medical care visit and avoidance of missed opportunities; and provider-based Assessment, Feedback, Incentives, and eXchange of Information interventions. However, one of the challenges we face is to introduce these strategies into the health care practices of every private provider within our jurisdictions. New public and private relationships are currently being forged throughout the country to determine how best to meet this challenge. Similarly, state and local immunization programs have identified programmatic strategies that work, as described by Santoli et al.5 at the Centers for Disease Control and Prevention. These interventions include development and widespread use of regional computerized immunization registries, enforcement of mandatory school and childcare immunization requirements, immunization assessment in U.S. Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics, and enhanced outreach, especially to ethnically diverse populations. Additional strategies need to be explored, including developing and implementing assessment interventions as part of welfare programs such as the Temporary Aid to Needy Families program. In addition From the County of San Diego Health and Human Services Agency (Ross), San Diego; and California Department of Health Services (Smith), Berkeley, California Address correspondence to: Natalie J. Smith, MD, MPH, Immunization Branch Chief, California Department of Health Services, 2151 Berkeley Way, Room 712, Berkeley, CA 94704. E-mail: Nsmith1@ dhs.ca.gov.