Take Your Best Shot

 TMA, Specialty Societies Launch Efforts to Boost Vaccinations  

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Public Health Feature -- March 2003  

By  Ken Ortolon
Senior Editor  

The development of vaccines is one of the great success stories in the battle to improve public health. Since vaccines were introduced, diseases such as smallpox and polio have been eradicated in the United States.

"Aside from sanitation issues, immunizations are the most effective public health intervention we've ever had," said Madisonville family physician Andrew C. Eisenberg, MD, a member of the Texas Medical Association Council on Public Health.

But Dr. Eisenberg and others say Texas is not doing a good enough job of protecting its citizens from diseases that could be prevented by vaccines. According to the National Immunization Survey conducted by the U.S. Centers for Disease Control and Prevention in 2000, Texas ranked last in the percentage of children aged 19 to 35 months who had received the full schedule of immunizations recommended by the Advisory Committee on Immunization Practices (ACIP). In 2001, Texas increased that percentage from 69.5 percent to 74.9 percent, but still ranked only 42nd. The national immunization rate was 78.6 percent.

Now, TMA is launching two major initiatives to combat low immunization rates and to ensure that children and adults in Texas get the vaccines they need. Those initiatives will include a major legislative push to increase the supply of vaccines and the number of health professionals administering immunizations and fix the state's immunization tracking system, as well as a major public campaign to educate parents and the general public on the importance of immunizations.

Focusing Attention  

The increased attention on immunizations comes on the heels of the resurgence of some vaccine-preventable diseases in Texas in the last few years. In 2001, for example, the incidence of pertussis, or whooping cough, rose dramatically to 615 cases, with several deaths. Only 152 cases of whooping cough were seen in Texas in 1999.

Also, fears that some diseases, such as smallpox, could be used as biological weapons have increased the importance of immunizations. (See "Smallpox, Big Decision," February 2003 Texas Medicine .)

In an immunization policy paper approved by the TMA House of Delegates in September, the TMA Council on Public Health outlined eight recommendations for improving Texas' immunization efforts. It said the state's failure to maintain a fully functional immunization registry, low reimbursement rates for physicians who provide immunizations through state-funded programs such as the Vaccines for Children (VFC) program and Medicaid, and lack of a statewide public education program on the importance of vaccines are among the problems that contribute to low immunization rates.

Developed with the Texas Pediatric Society (TPS), the Texas Academy of Family Physicians, and the Texas Academy of Internal Medicine, the council's recommendations call on the Texas Legislature to:

  • Improve the state's current immunization tracking system,
  • Improve immunization education for both physicians and parents,
  • Address public and private vaccine financing issues,
  • Increase physician education and participation in the VFC program,
  • Improve vaccine distribution under the VFC program, and
  • Conduct a feasibility study of a universal vaccine purchase program.

The council also recommended developing a way to allocate and distribute vaccines in case of a bioterrorist attack, and action to address recent vaccine shortages, both of which likely would require federal action.

The recommendations were presented to the interim Senate Committee on Health and Human Services in 2002 and were included in its recommendations to the legislature. State Sen. Judith Zaffirini (D-Laredo) subsequently filed six bills that address the bulk of the legislation.

They require the Texas Department of Health (TDH) to develop materials and continuing medical education programs on immunizations and the VFC program for physicians, streamline the application process to become a VFC provider, and improve reimbursement rates. The legislation also would shift the state's immunization tracking system, ImmTrac, from a system in which parents have to "opt in" to have their child's immunization record included in the registry to a system in which all records would be included unless the parents "opt out." TDH would be responsible for determining whose parents or guardians have not consented to inclusion in the registry. That burden currently falls on physicians.

Other bills would create a continuous statewide public education program on the importance of fully immunizing children, require health plans to cover all immunizations recommended by ACIP, authorize the state comptroller to study the feasibility of implementing a universal vaccine purchase plan and other vaccine delivery alternatives in the state, and require TDH to report to the legislature the results of a TPS pilot study of physician-to-physician immunization education in Houston.

Keeping Track  

San Angelo pediatrician Jane Rider, MD, says vaccine record keeping is a huge problem contributing to low immunization rates. Because patients change health plans and medical homes frequently, it is hard for physicians to track their immunization histories. And parents frequently fail to provide immunization records during office visits. As a result, the records aren't updated and parents lose track of their child's immunization status.

"When you ask for the immunization record and the parent doesn't have it, the parent, with rare exception, will say his or her child is up to date," Dr. Rider said. "But when you delve deeper, when you finally track down those records, usually you find the child is not up to date for a variety of reasons. Maybe doses were skipped or new immunizations have come out or the schedule has changed."

And under-immunization is not the only problem. San Antonio pediatrician Dianna Burns, MD, says recently a mother brought in a child for immunizations but failed to bring his immunization records. When Dr. Burns pulled the ImmTrac records, she found the boy had been over-immunized.

"Actually, he had already received 10 DTP [diphtheria-tetanus-pertussis] shots and four MMR [measles-mumps-rubella] shots," Dr. Burns said.

Both pediatricians say much of the record-keeping problem could be solved if ImmTrac were a fully functional immunization registry. Unfortunately, few immunizations being provided outside of the VFC program and Medicaid are being reported to ImmTrac, they add.

ImmTrac was developed in the mid-1990s and implemented with legislative authority in 1997. However, under a 1999 law, parents must give consent to have their child's immunization records included in the registry. That consent can be obtained by having the parent check a box on the birth certificate application, or the provider administering the vaccine can obtain consent and note it in the patient's file.

Even though well over 90 percent of Texas parents grant consent or "opt in," many immunization records never make it to the registry. Theoretically, immunization information is supposed to enter the registry from the TDH Bureau of Vital Statistics, Women, Infant, and Children clinics, Medicaid, the Integrated Client Encounter System (ICES), private health care professionals, and private health plans. State law requires health plans to report all vaccines they pay for, and health care professionals are required to report vaccines paid for by cash or public funds.ICES is a computer program developed by TDH to automate much of the documentation and record keeping required in public health clinics.

But ImmTrac Director David Scott says TDH is getting no data from the health plans because they do not track consent. "They don't have to report if consent has not been obtained or if it's been withdrawn," he said.

Because the HCFA-1500 form, which most plans use for claim filing, does not include a place to indicate consent, the plans can conveniently claim they do not know whether consent has been obtained and, therefore, decline to submit the records, Dr. Eisenberg says.

Opt Out Versus Opt In  

In 2001, TMA and other immunization proponents unsuccessfully supported legislation that would take the onus of getting consent off the health plans and physicians by changing ImmTrac from an opt-in to an opt-out system. Under an opt-out approach, all immunization records would go into the registry unless a parent specifically requested that the child's records be kept out. TDH would have had the responsibility of tracking requests to withdraw from the registry and insuring that those records were removed.

Senate Bill 39, filed by Senator Zaffirini, includes similar opt-out language, but the measure has generated opposition from groups concerned about privacy of medical records.

Dawn Richardson, president and cofounder of Parents Requesting Open Vaccine Education (PROVE), says parents should not be asked to forfeit their right to consent to the release of their children's records. Parents, she adds, have the right to maintain those records themselves and keep them private between themselves and their child's physician.

"There is a tradition in medicine to hold the patient record as private and confidential," said Ms. Richardson. "That's what builds trust between the physician and the patient."

PROVE is an organization of about 3,500 Texas families concerned about both privacy issues and potential vaccine side effects. Ms. Richardson says most PROVE members have their children vaccinated but do so "selectively."

Mr. Scott says only about 200 families have opted to withdraw consent to have their children's records included in the registry since 1998.

Dr. Burns says most parents welcome the registry. "If we lived in an ideal world, having the parents keep track would work terrifically," she said. "But with the way insurance works today and the frequency with which patients change health plans and providers, that's not the reality. We need to be able to know our immunized population. We need to be able to access that information."

Getting Physicians Involved  

The second major problem that the Council on Public Health recommendations and Senator Zaffirini's legislation attempt to address is the shortage of physicians participating in the VFC program. The council blamed low participation on the fact that many physicians don't fully understand the program and regard it as another administrative burden on their practice.

Another problem is low reimbursement for administering vaccines. While the physician receives the vaccine free from the state and does not charge the patient for the vaccine itself, the state pays $5 for each vaccine administered. However, the council estimates that actual in-office costs for administering each vaccine -- including the cost of supplies, staff time, and physician's time -- is $8.13.

"A lot of providers are not members of Vaccines for Children because giving vaccines in your office is a losing proposition," Dr. Eisenberg said. "You lose money, you lose time, you lose resources."

The council recommends the state increase the administration fee to cover the physician's cost and provide a reasonable profit. Dr. Rider says that might be hard to achieve this year with lawmakers staring at a $9.9 billion budget deficit.

Taking Our Best Shot  

While immunization advocates work to enact the council's recommendations, TMA is preparing to launch a public and physician education campaign to take on sagging immunization rates directly. The campaign, being developed by TMA's Joint Committee on Health Improvement Initiatives, likely will be a five-year program that will bring together corporate entities, government agencies, and organized medicine to mount a sustained campaign to improve vaccination rates.

"We want to ensure that this is not just an emphasis on one-time immunizations but that we put into place a system for follow-up so that we have continuity and children continue to get the subsequent immunizations at the appropriate times," said Charles W. Bailey Jr., MD, TMA president-elect and chair of the joint committee.

Still under development, the project likely will include:

  • Continuing medical education for family practitioners, pediatricians, and other primary care physicians;
  • A public awareness campaign;
  • Tools for physicians to use in their offices; and
  • Targeted direct-care immunization efforts.

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.  

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