Evaluation of a Legislatively Mandated Influenza Vaccination Program

Evaluation of a Legislatively. Mandated Influenza Vaccination Program for Adults in Rhode Island National Immunization Conference April 1, 2009 Faruque Ahmed 1, Virginia Paine 2, Fan Zhang 1, Edith Gary 1, Peng-Jun Lu 1 1 Centers for Disease Control and Prevention 2 Rhode Island Department of Health TM

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

Population: 1. 1 million (80% NH White, 11% Hispanic, 6% Black) Area: 1214 sq miles (length: 48 miles, width: 37 miles) TM

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 TM

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 2007 -08 season TM

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 *Uninsured adults to be referred to a provider who is part of the approved community network for the uninsured TM

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 nonparticipating providers – Supported by Adult Flu Advisory Group, Pediatric Immunization Advisory Group, Primary Care Physician Advisory Committee, Adult Immunization Coalition, and health insurers TM

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

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 TM

Participating Providers Private practices Nursing homes Health centers Urgent care facilities Hospitals Businesses Mass immunizers State agencies Other Number 249 72 32 22 17 8 7 2 3 TM

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 TM

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 TM

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 TM

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 TM

Evaluation TM

Evaluation • Key informant interviews – 25 providers • Provider survey – Response rate = 35% (144/412) • BRFSS* – Rhode Island vaccination rate – U. S. vaccination rate *Flu vaccination during the past 12 months TM

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 TM

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 TM

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 TM

PROVIDER SURVEY Enrollment and Training Online enrollment process was userfriendly Satisfactory and timely assistance with enrollment Choice of convenient training session times and locations Received adequate information about the program Yes or Agree (%) 93 96 90 97 TM

Vaccine Ordering and Shipment Received the amount of vaccine ordered If requested more vaccine later, received it Initial vaccine shipment before the October 17 start date Distributor clearly communicated vaccine delivery date Yes or Agree (%) 97 89 87 87 TM

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

Claims and Payments Provided with information on how to file claims Difficulties in receiving reimbursement from insurers* Had to pay for unused or spoiled vaccine Yes or Agree (%) 78 30 17 *For vaccine administration TM

Overall Assessment Plan to enroll for the 2008 -09 influenza season Would encourage other providers to enroll Overall satisfaction Yes or Agree (%) 98 95 94 TM

Factors Associated with Overall Satisfaction Choice of convenient training session times and locations Agree Disagree Influenza program paperwork was reasonable Agree Disagree n Overall satisfaction (%) 124 14 96* 79 97 40 98* 83 *P < 0. 05 (also significant in multivariate logistic regression model) TM

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 TM

BRFSS Influenza Vaccination Rate (%) Age 65 and older (Preliminary) Rhode Island U. S. 2006* (Pre) 80. 7 2007† (Post) 83. 2 67. 5 70. 3 *BRFSS interviews during December 2006 †BRFSS interviews during December 2007 TM

Conclusions • High satisfaction with – Enrollment and training – Vaccine ordering and shipment • Lower satisfaction with – Paperwork – Claims for vaccine administration • High overall satisfaction with program TM

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

Questions? Virginia Paine Rhode Island Department of Health Virginia. Paine@health. ri. gov Faruque Ahmed Centers for Disease Control and Prevention Fahmed@cdc. gov TM