Public Health Feature - July 2007
By Crystal Conde
Seven years ago, the Texas immunization landscape was bleak. The U.S. Centers for Disease Control and Prevention's 2000 National Immunization Survey ranked Texas last in the nation for the number of children aged between 19 and 35 months who had received the 4:3:1 vaccine series. Four years later, Texas climbed to 41st and today rests at 24th.
Immunization initiatives and health care professionals' efforts have helped close the gap. Even so, vaccinating the population hasn't gotten any easier. Ever-expanding immunization schedules, combined with inadequate reimbursement by health care payment plans and the cost of administering and storing increasingly expensive vaccines, place a burden on primary care physicians.
That's where the Texas Medical Association Be Wise - Immunize SM program comes in. To increase statewide immunization rates, promote immunization as an effective and safe way to prevent disease, and help physicians manage their practices through education, communication, and action, TMA launched the latest Be Wise resource at TexMed 2007 in April.
The Be Wise - Immunize Physician Toolkit is a 44-page booklet physicians can turn to for best practice guidelines, communication tools, immunization schedules, ImmTrac Texas Immunization Registry information, outreach initiative details, vaccine safety standards, and other Texas-specific resources. It also includes promotional flyers and posters for patients in English and Spanish. The toolkit's initial rollout encompasses 200 copies.
Practices without Internet access can request a booklet while supplies last by contacting the Be Wise coordinator at (800) 880-1300, ext. 1470, or (512) 370-1470. An online version of the toolkit can be accessed on TMA's Web site at www.texmed.org/bewise. The Be Wise section of the Web site also provides a wealth of immunization-related resources and allows physicians to become Be Wise Immunization Advocates.
Since its inception in 2004, 69,000 shots have been administered under Be Wise - Immunize, a joint initiative led by TMA member physicians and the TMA Alliance. The alliance has been instrumental in the program's success. Members have joined or formed coalitions in their local communities and have sent out mobile clinics to help improve the immunization rate statewide. The TMA Foundation provides funding for the program. Gifts from Cook Children's Health Care System in Fort Worth, Texas Children's Hospital in Houston, and the American Medical Association Foundation's Fund for Better Health made the toolkit possible.
At press time, TMA also was backing several pro-vaccination bills in the 2007 session of the Texas Legislature. A wrap-up on the fate of those and other bills TMA supported or opposed will be published in the August issue of Texas Medicine.
In developing the immunization toolkit, TMA's Public Health Department convened an eight-member panel of physicians and spent about a year compiling information for the booklet.
Andrew Eisenberg, MD, a family physician and panel member, says the toolkit is constantly evolving with the continued expansion of immunization schedules and new vaccines hitting the market. "The biggest benefit is going to be its use as a one-stop shopping resource," he said. "There's more up-to-date, focused information and tools in one spot that physicians can access."
Among those tools is a chapter dedicated to communicating with parents, including information about thimerosal and conscientious objection. The thimerosal portion of the toolkit contains a brief history of the mercury-in-vaccine scare that began in 1997 when the U.S. Food and Drug Administration called for a review of all food and drugs containing mercury.
The toolkit offers physicians expert opinion from the Centers for Disease Control and Prevention, the Institute of Medicine, and the National Institute of Allergy and Infectious Diseases so they can address parents' concerns about immunization. The toolkit's conscientious objection section gives physicians talking points they can use to counter objections and informs health care professionals of what's required for exemptions from vaccination. Physicians will find the exemption-from-immunizations sample request form helpful in working with patients who require an exemption.
The talking points cover how physicians can maximize their counseling time in the office, how they can alleviate patients' concerns about issues such as potential side effects, and how to keep communication open with patients. Examples include:
- Respect and address concerns - provide factual information in language that's easily understood, addressing the specific concerns or misconceptions that patients have about vaccination;
- Educate about responsibilities - inform parents who defer vaccination for themselves or their children of their duty to protect other family and community members; and
Explore acceptable options - determine whether patients or parents are willing to allow themselves or their children to receive certain vaccines, be immunized on an alternative schedule, or delay vaccination.
Ari Brown, MD, an Austin pediatrician and member of the advisory panel, spends a lot of time counseling parents about why it's important to vaccinate their children. She says the toolkit's talking points help doctors anticipate patients' questions and concerns. "When you're prepared and know what parents are hearing, there are no surprises," she said.
Another panel member, Edward Dominguez, MD, specializes in infectious diseases and internal medicine in Tyler. He recognizes the toolkit's ability to help doctors address parents' legitimate concerns, while educating them about what conscientious objection entails.
"Maybe the next year they'll decide to get the vaccine. After use of toolkits like this, there is a sense that more people will get the vaccines once they've been informed," Dr. Dominguez said.
One of the toolkit's strengths is its online presence, which allows for quick searches by topic. Dr. Dominguez expects patients to use the toolkit to learn more about the immunization process and to understand why getting vaccinated is important.
Improving communication and familiarizing the public with immunization requirements aren't the toolkit's only targets. Dr. Brown hopes it will educate and inform doctors who haven't customarily given vaccines in their practices.
"Traditionally, pediatricians and family physicians have carried the bulk of vaccinating our population," she said. "Now with the expansion of our vaccination schedules, internal medicine doctors and obstetricians need to also embrace vaccines as a part of their daily practice."
Adding to the vaccination load on primary care physicians are the 22-plus new vaccines TMA Council on Public Health member Molly Droge, MD, expects to hit the market in the next five to 10 years. "If we're going to be giving more vaccinations to adolescents and adults, it's going to be important for adult providers to be willing to participate," she said.
Be Wise - Immunize is a registered service mark of the Texas Medical Association.
Crystal Condecan be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at Crystal Conde.
Physicians Face Crisis in Vaccine Reimbursement
The American Academy of Pediatrics (AAP) Task Force on Immunization estimates that it cost a private practice $1,641 to immunize one child last year. In 1980, it cost about $23, and children received only seven injections. Today, they get 22 to 33, depending on whether physicians use combination vaccine products.
As immunization schedules expand and vaccine prices increase, neither public nor private payers are keeping up with costs. When doctors have to invest thousands of dollars in vaccines and fail to receive full reimbursement from health care payment plans for months, that's an investment they can't afford to float. The situation places unbearable demands on primary care physicians and threatens their ability to continue to deliver vaccines in a patient's medical home.
TMA Council on Public Health member Molly Droge, MD, recognizes that primary care physicians have been "holding the boat up" for a long time and can't continue to do so. "We are subsidizing the immunization program, and the fat is gone and the muscle's gone; we're down to the bone," she said. "It doesn't work if physicians can't afford to purchase the vaccine. It doesn't work if physicians lose money every month. We are small businesses, and we have to be able to pay our bills like everyone else."
Ending the reimbursement crisis requires a discussion at the national level about immunization financing and payers' acknowledgment of the real costs of vaccines. "Primary care practices need to be adequately reimbursed not only for the vaccine products, but also for the overhead costs to the practice and the administration fees to provide the vaccines to the patients," Dr. Droge said.
According to the AAP Task Force on Immunization, vaccines save $10 billion in direct costs and $43 billion in societal costs in the United States each year. In addition, the task force reports that vaccines prevent 14 million cases of vaccine-preventable diseases for every birth cohort of immunized children.
"We're not just immunizing a child, we're protecting the community," Dr. Droge said. "The payers are benefiting by having the best immunization rates that we can have because they don't have to pay the costs for treating the diseases that immunizations prevent."
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