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Recovering Routine Immunization Rates — State Strategies to Move beyond COVID-19

Medicaid Agencies Cultivate Partnerships and Deploy Data to Bolster COVID-19 Vaccination Efforts

March 29, 2021/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Health IT/Data, Medicaid Managed Care, Population Health, Program Design, Quality and Measurement, Social Determinants of Health, Special Populations and Services, Vaccines /by Christina Cousart

COVID-19 vaccine distribution has accelerated across states as the Biden Administration updates its vaccine goal to 200 million doses by April 23, 2021 and many states are opening eligibility to all adults by early April. The National Academy for State Health Policy (NASHP) recently spoke with several state Medicaid officials to learn more about how their agencies – and specifically their Medicaid managed care organizations (MCOs) – are leveraging partnerships and data to advance their vaccination efforts.

Leadership and communication across state agencies are enabling optimal coordination.

States’ COVID-19 vaccination efforts are primary led by their departments of health (DOHs), but nearly every other state agency plays a role in helping to raise awareness with the constituencies they serve or by aiding with vaccine logistics and administration – often both. To reduce confusion, agencies must work in lockstep, agreeing on policies while using similar messaging and data sources to promote accurate information about the vaccine. In the case of Medicaid, state officials work not only to convey vaccine updates from their state DOH to Medicaid enrollees, but also to the health plans and providers they work with. Medicaid agencies have revised call center scripts, website content, and other resources so they are in line with the latest language put forth by their DOHs.

View state-by-state vaccination eligibility plans at: State Plans for Vaccinating their Populations against COVID-19.

To improve coordination, Medicaid agency officials participate in, and sometimes lead, weekly meetings with state and county officials to update them about the latest vaccine progress. They have also worked with state and county officials to identify and share data about Medicaid enrollees to enable improved targeting of high-risk, and/or priority populations for outreach by state and local authorities. Medicaid agencies have also shared data about provider networks to aid vaccine administration efforts. Specifically, data has been used to recruit providers who are already actively engaged in serving certain populations as part of direct vaccination efforts, including as vaccine administrators at mobile vaccination sites.

Empowering Medicaid health plans encourages innovative vaccination promotion strategies.

Along with collaborating with state and local agencies, Medicaid agencies have also cultivated stronger relationships with their MCOs and other participating health plans to promote vaccinations. Several states’ officials report meeting with their health plans on a biweekly or weekly basis to share the latest updates on vaccination policy, as well as to strategize about best practices to encourage vaccination. United by a mutual goal of encouraging members toward health and away from catastrophic illness, the vaccination effort provides a unique opportunity for Medicaid to work in partnership with its health plans and encourages innovative approaches to improve vaccination rates. Some innovative strategies include:

Distributing educational material about how to schedule appointments and appointment reminders;
Enabling plans and plan representatives to schedule appointments on behalf of enrollees;
Active post-vaccination outreach to assess vaccine side effects;
Communication to family members and care takers about vaccine eligibility and access; and
Development of training modules for care managers to address vaccine hesitancy.

Several officials especially noted the challenge of ensuring transportation to and from vaccination sites. To mitigate these issues, states have employed various methods of moderating this barrier – from providing access to free transportation services to mandating that health plans cover transportation to and from vaccination sites. One state had a policy to reimburse enrollees for miles traveled, while another worked with carriers to set a rate for transit services that included a “wait time” between arrival at and departure from the vaccination site.

Access to state data is critical to health plan participation in vaccination efforts.

Beyond sharing strategies to encourage outreach and access to vaccination sites, Medicaid agencies have played a key role in sharing critical data about Medicaid enrollees directly with MCOs or other participating carriers.

Medicaid agencies have unique access to state data sources, including Medicaid enrollment and claims data and vaccination data from public health data repositories, which is otherwise not available to private companies or other agencies. Access to this data not only positions a state Medicaid agency to take an active role in identifying enrollees to target for vaccination outreach, but it also enables it to perform analytics across data sources. For example, some states are cross-walking vaccine registry data with Medicaid data to identify Medicaid recipients who have scheduled vaccination appointments or who have been vaccinated. This ability to crosswalk data from vaccine registries is especially important, as many vaccines are scheduled and administered without an insurance claim, leaving health plans without any information about the vaccination status of their enrollees. However, armed with Medicaid data and analytics, health plans are able to conduct direct follow-up with their members. In several cases, states report active participation from health plans that are using data to encourage vaccination, including among high-risk individuals. Others go further and connect enrollees with case managers who may be able to assist with arranging transit to and from appointments or scheduling follow-ups for the second vaccine dose.

Capacity to conduct complex analytics may be limited based on states systems’ ability to extract and share data across agencies, and outdated claims processing systems may affect the timeliness of available data. Meanwhile, vaccination databases are in the midst of being brought to scale in tandem with escalating vaccination efforts, and data may not yet be fully accessible or up to date in state systems. State agencies are rapidly working to improve data capacity, including efforts to enable direct connections between carriers and providers to data sources or analytic information. One state also reported efforts to access data from border states, to ensure it had updated vaccination information even for those that may get vaccinated outside of the state.

States have and continue to rapidly adapt in response to the ever-evolving pandemic. As vaccine capacity increases, they will continue to build on their growing resources and infrastructure to address changing needs and circumstances. As they do, NASHP will report on the development of new policies and promising practices from those at the forefront of addressing the COVID-19 crisis.

States Identify and Address COVID-19 Vaccine Disparities through Targeted Rollout and Outreach

February 8, 2021/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Health Equity, Population Health, Social Determinants of Health, Vaccines /by Rebecca Cooper, Ariella Levisohn and Jill Rosenthal

As states rapidly work to get COVID-19 vaccines into arms as quickly as possible as viral variants spread, state officials know vaccine rollout plans must focus on equitable distribution to communities of color, especially Black and Latinx communities that have experienced disproportionately high infection rates, hospitalizations, and deaths. However, early data suggests that these populations are receiving vaccines at lower rates than White Americans.

As President Biden highlights his administration’s commitment to equity, officials from a cross section of states told the National Academy for State Health Policy (NASHP) how they are working to simultaneously build and strengthen systems to track and address disparities in COVID-19 vaccine administration.

The Biden Administration’s National Strategy for the COVID-19 Response emphasizes equity in vaccine distribution to “protect those most at risk and advance equity, including across racial/ethnic and rural/urban lines.” This includes increasing data collection and reporting for high-risk groups, supporting communities most at risk of COVID-19, and ensuring equitable access to critical COVID-19 personal protective equipment, tests, therapies, and vaccines. These steps help achieve equity by identifying underserved communities, sending them extra vaccine supplies, improving public trust in the vaccine, and ensuring individuals are able to get vaccinated.

Recently, the Biden Administration announced it will begin shipping an additional 1 million vaccine doses each week to thousands of pharmacies across the country in an effort to improve equity and increase access to the vaccine.

Preliminary data highlights vaccine disparities:

As of Feb. 8, 2021, less than 3 percent of the US population had been vaccinated with both doses to date. Though data is limited and race and ethnicity are widely underreported, preliminary data does show racial disparities.

The US Centers for Disease Control and Prevention’s Feb. 1, 2021 Morbidity and Mortality Weekly Report noted that to date 60.4 percent of vaccine recipients were White and 39.6 percent were people of color.

However, only 50 percent of the 6.7 million doses administered through Jan. 14, 2021 documented the race and ethnicity data of vaccine recipients.

The available data highlights disparities in communities of color:

• 4 percent of vaccine recipients were Black (though Black people make up 12.2 percent of the population); and

• 5 percent self-reported as Hispanic/Latino (who make up 18.5 percent of the US population).

Pharmacies will be a critical venues for vaccine access, and this pharmacy distribution program is expected to build that capacity as the US Centers for Disease Control and Prevention (CDC) and state health directors work together to identity areas of need and ship vaccines to pharmacies in those areas, especially in the early days of the program when distribution is still curtailed by limited vaccine supplies. State officials told NASHP that the selection of pharmacies will be based on their ability to both reach the most vulnerable populations and also align with states’ current distribution phases and priority populations in their vaccination plans.

Pandemic responses have shown that federal leadership is key to success. The following examples highlight how state efforts to collect and analyze trends in race and ethnicity data, supported by strong directives from the White House and a centralized federal task force, can guide decision making and promote the implementation of concrete strategies to reduce disparities.

For more information on which states are tracking vaccination data by race and ethnicity, explore NASHP’s interactive map.

Tracking and Reporting Race and Ethnicity Data

One of the first steps to ensure equitable access to vaccines is having the data to determine where disparities exist. Forty-eight states and Washington, DC currently collect and share varying levels of vaccine data in publicly available data dashboards. Of these, 26 states and Washington, DC publicly display race and ethnicity data for individuals who have received their vaccines. States report the data slightly differently – which can result in different conclusions about their efforts. They are reporting either:

Total number of individuals vaccinated by race and ethnicity (for example, Florida and Pennsylvania);
Percentage of total individuals of each race or ethnicity in the state who have been vaccinated (North Dakota); or
Percent of total doses that have gone to individuals by each race and ethnicity (Indiana and North Carolina).

While these state trackers provide some insight into who is getting vaccinated, there are limitations in their data – a large percentage of race and ethnicity data is either missing or not reported. Nationwide, race and ethnicity data is missing for nearly half of those vaccinated, compared to age and gender data, which is reported 99.9 and 97 percent of the time, respectively. Even in states that collect and publicly report this data, some report over 50 percent of doses with “unknown” race and ethnicity. Providers will report “unknown” in the race and ethnicity fields either because the providers do not ask for the data, or because the recipients do not provide it. It is unclear why individuals are declining to provide their race and ethnicity, but some experts believe that some concerns may stem from a fear that their demographic data could be misused. For example, immigrants are concerned that getting the vaccine – or providing their data – may negatively affect their immigration status. However, the CDC said that vaccine data cannot be used for immigration enforcement, and that getting the COVID-19 vaccine will not be considered as part of the public charge inadmissibility rule.

Many states are working to improve their data collection and reporting. Some, such as Alabama, are collecting race and ethnicity data but have not yet made it public because it is incomplete. These states are working to collect complete and accurate data before publishing it. Most states that are reporting race and ethnicity data publicly do not require providers to include that information, citing a lack of express permission from the patient or concern that requirements might prevent providers from reporting vaccine doses at all.

Other states are imposing requirements to improve data. In North Carolina, Department of Health and Human Services Secretary Mandy Cohen pushed to make race and ethnicity a required field in the state’s COVID-19 vaccine registry. According to state officials, North Carolina emphasizes equity as a core value and conducts outreach and training with providers to emphasize the importance of race and ethnicity data. The availability of the data has enabled outreach strategies, such as partnerships with faith leaders.

While requiring providers to upload race and ethnicity data can add to administrative and logistical challenges, collecting the data is critical to ensuring that vaccine outreach and administration are targeted to the communities most in need. If large percentages of race and ethnicity data are missing, ensuring equity in distribution becomes much more difficult.

State Strategies to Reduce Disparities in Vaccination

Tracking disparities by identifying gaps in data is only the first step. In response to early data that showed disparities, states are taking action to address inequity by scheduling clinics in high-need areas, facilitating vaccination in high-priority zip codes, and tailoring communications to address vaccine hesitancy. President Biden’s plan to add to states’ allotments by sending vaccines directly to local pharmacies beginning Feb. 11, 2021 will also aid in the goal of an equitable distribution. Pharmacy partners were selected in part based on their ability to reach socially vulnerable populations, and the program will follow each state’s current eligibility requirements to ensure individuals, especially those in high-need areas, have access to the vaccine. States are also currently working to reduce disparities by using strategies to increase access to, and comfort level with, the vaccine.

Many states are using the CDC’s Social Vulnerability Index (SVI) to identify areas of high need where vaccine distribution efforts should be targeted. The SVI is a CDC tool that uses US census variables – including socioeconomic status, transportation access, housing status, and language – to rank areas in order to help public health officials prepare for and respond to emergency events. A high ranking indicates that an area may need more support for their emergency response – in this case vaccination distribution and administration.

Locating Clinics in High-Need Areas

Delivering vaccines to underserved communities is key and the new Federal Pharmacy Program helps address this goal. States and local health departments can use preliminary data to identify counties or jurisdictions with disparities and low rates of vaccination uptake to use to target their vaccination efforts.

Rick Palacio, the cochair of Colorado’s COVID-19 Vaccine Equity Taskforce, announced that one of the state’s goals is to hold pop-up vaccination clinics in half of the state’s top 50 census tracts containing low-density, low-income communities. Officials emphasized the importance of using data to determine under-vaccinated areas and tailor communication strategies to reach those residents. The state kicked off this plan by vaccinating more than 10,000 seniors at a mass vaccination event in Denver and plans to expand the initiative as it receives more doses.

Other examples of state efforts to identify and reach underserved areas include:

Rhode Island is using its hospitalization, death, and case data to target vaccine distribution by geography. Vaccines will be available in community clinics, pharmacies, and housing sites in communities that have been identified as high risk.
Illinois has had success by holding events scheduled by local health departments that reached out to discreet, hard-to-reach communities and invited them to register for a vaccine appointments.
Connecticut is closely tracking vaccine rollout in localities that rank high on the social vulnerability index.
After Washington, DC opened its vaccine registration portal to all individuals over the age of 65, data quickly showed that an outsized proportion of appointments was going to wealthier White residents. In response, health officials made more appointments available for residents in parts of the city that were currently securing the fewest vaccine appointments. The city also started making appointments for residents in these high-priority zip codes available a day before other eligible residents could register.
North Carolina has partnered with faith leaders to ensure communities of color and underserved communities have access to vaccinations at the state’s mass vaccination clinics, including releasing appointments to Black and Latinx church attendees before opening up registration to the general public.

States can also reduce transportation barriers to increase vaccination uptake and ensure transportation will not be a barrier for targeted populations to access the vaccine. North Carolina’s mass vaccination clinic location was chosen for its proximity to public transportation.

The Tennessee Department of Health (TDH) is expanding access to the COVID-19 vaccine by focusing on increasing vaccinations in rural and underserved areas. TDH partnered with pharmacies and community health clinics to add over 100 vaccination sites across the state, focusing on “hard-to-reach” areas, as identified in the state’s vaccination plan. Tennessee’s state plan indicated that 5 percent of the state’s allocation of COVID-19 vaccines are earmarked for use in targeted areas with vulnerable populations.

Additionally, at a February US House Energy and Commerce Oversight and Investigations Subcommittee hearing, Louisiana state officials cited a plan to create community mobile strike teams that will travel to areas that rank high on the social vulnerability index to administer vaccines. The strike teams will be staffed by the National Guard and funded by the Federal Emergency Management Administration, which reimburses states for 100 percent of costs associated with the National Guard’s COVID-19 relief efforts. A state official in Michigan also noted at this hearing that the increase in doses from the federal government will help advance equity, because those extra doses can be distributed directly to underserved areas and minority populations.

Tailoring Communication Strategies to Address Vaccine Hesitancy

While reporting and tracking vaccination data and removing logistical barriers are important strategies for identifying pockets of need, they alone are not sufficient to reduce disparities. A history of racism in the health care system has led to distrust by communities of color. Though the share of adults planning to get the COVID-19 vaccine has increased over the year, according to recent surveys White adults (53 percent) remain more likely than Black (35 percent) and Latinx (42 percent) individuals to want to be vaccinated as soon as possible. A survey last fall found that less than 20 percent of Black Americans trusted vaccine safety and efficacy. The survey also indicated that the best messengers to support vaccination in these communities are those living in their own communities, or their health care providers.

State officials and several members of the federal Advisory Committee on Immunization Practices (ACIP) mentioned that the desire to vaccinate quickly must be balanced with the need to reach vulnerable communities. State officials note that balancing speed and equity is one of the biggest challenges they face. Community input builds trust and assists in building effective and acceptable strategies. For example, Tennessee has an African American Health Care Clinician Workgroup, with working members from the NAACP, the Black Nursing Society, and other Black organizations, who are disseminating messaging on the importance of vaccinations and will ultimately help vaccinate Black communities. The Colorado Department of Health and Environment has released commercials in English and Spanish featuring Colorado health care workers who are people of color, promoting the message that vaccines are safe. West Virginia is funding faith-based community members and people of color to administer COVID-19 vaccines directly to communities of color, ascribing to the principle that having trusted, local figures helping with distribution will improve those communities’ confidence in the vaccine.

Conclusion

Federal and state governments are working to vaccinate residents as quickly as possible, while also working to ensure doses are equitably distributed. In light of reports of disparities in vaccination rates and in vaccination access among people of color and in rural communities, the Biden Administration is acting on its promise to ensure an equitable distribution, including their new strategy to ship extra doses to pharmacies in hard to reach areas. While distribution strategies vary across states and are continually tweaked to improve efficacy and equity, the emerging best practices:

Use data to track and identify under-vaccinated areas and populations;
Set up additional clinics in underserved areas and provide additional doses to these clinics;
Ensure transportation is available for patients to access the clinics; and
Partner with local agencies and community organizations to promote vaccine confidence.

Each of these components is necessary to ensure underserved communities and communities of color are interested in receiving vaccines and are able to access them.

This analysis is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $200,000 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: February 2021

Six States Join NASHP and AcademyHealth’s Community of Practice to Boost Immunization Rates in Medicaid-Enrolled Pregnant Women and Children

January 11, 2021/in Policy Louisiana, Michigan, Washington, Wisconsin, Wyoming Blogs, Featured News Home Chronic Disease Prevention and Management, Health Equity, Immunization, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health /by Rebecca Cooper, Jill Rosenthal and Ariella Levisohn

The National Academy for State Health Policy (NASHP) and AcademyHealth, with support from Immunize Colorado, are facilitating a new community of practice (CoP) comprised of state health officials from six states interested in improving their immunization rates.

Funded by a US Centers for Disease Control and Prevention (CDC) cooperative agreement, the Immunization Barriers in the United States: Targeting Medicaid Partnerships program is engaging six state Medicaid agencies (LA, MI, TX, WA, WI, WY) in collaboration with their public health and immunization information system partners. Through this CoP, states are working to improve Medicaid policies and outreach to increase immunization rates among low-income children and pregnant women. The project will build on the work and lessons learned from the previous CoP of five states, which ended in late 2020.

Despite coverage of vaccines through Medicaid, immunization rates among children and pregnant women enrolled in Medicaid remain lower than those who are privately insured and have higher incomes. Disparities in vaccine coverage exist for Black women and people living in poverty. Additionally, CDC data shows a significant reduction in routine vaccines administered to children during the COVID-19 pandemic. While vaccination rates are slowly returning to pre-pandemic rates, national experts are concerned that the missed vaccine doses may have future health implications and lead to outbreaks of vaccine-preventable diseases.

Through virtual and in-person meetings over the course of the three-year project, AcademyHealth and NASHP will provide technical assistance to states, identify barriers, and share promising practices for increasing immunization rates.

State Immunization Services and Policies Resource Page

November 3, 2020/in Policy Toolkits Chronic Disease Prevention and Management, Healthy Child Development, Immunization, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health Immunization /by Rebecca Cooper

States Invited to Join a Community of Practice to Improve Immunization Rates

November 2, 2020/in Policy Blogs, Featured News Home CHIP, CHIP, Chronic Disease Prevention and Management, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Immunization, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by NASHP Staff

The National Academy for State Health Policy (NASHP) and AcademyHealth are seeking five to seven states to join a community of practice focused on improving immunizations rates.

To apply, complete an expression of interest form by Dec. 10, 2020.

Download Form

Funded by the Centers for Disease Control and Prevention (CDC) cooperative agreement entitled Eliminating Barriers to Immunization through Collaborative Use of State Agency Resources, each state’s community of practice will be comprised of a multidisciplinary team, including a Medicaid medical or policy director, an immunization state program manager, and a state immunization information system coordinator.

Through virtual and in-person engagement over the course of the three-year project, NASHP and AcademyHealth will work with states to identify immunization barriers and share promising practices for increasing immunization rates for children and pregnant women enrolled in Medicaid.

If a state’s Medicaid agency is interested in joining this community of practice, please send an email to Sunita Krishnan (Sunita.Krishnan@academyhealth.org ) with a completed expression of interest form by Dec. 10, 2020.

Explore NASHP’s State Immunization Services and Policies Resource Page for more resources.

Webinar: Avoiding Dual Epidemics – State Strategies to Prevent Flu during COVID-19

October 13, 2020/in Policy Arizona, Illinois Webinars Chronic Disease Prevention and Management, COVID-19, Health Equity, Population Health, Social Determinants of Health /by NASHP Staff

Strategic planning for the 2020-2021 flu season during the COVID-19 pandemic is critically important to ensure that states do not experience dual epidemics this year. In this November, 2020 webinar, NASHP, in partnership with AcademyHealth and Immunize Colorado, provided a national overview of flu prevention priorities from the Centers for Disease Control and Prevention (CDC), and a closer look at state strategies in Arizona and Illinois.

Speakers discussed how states can ensure equitable access to the flu vaccine, including expanding access to immunizations through pharmacies and other delivery sites to reach vulnerable populations, and various payment and reimbursement strategies. This webinar was funded by the CDC.

Participants included:

Moderator: Jill Rosenthal, MPH, NASHP Senior Project Director
Sam Graitcer, MD, CDR, Medical Officer and Pandemic Influenza Coordinator, Centers for Disease Control and Prevention
Jami Snyder, MA, Director, Arizona Health Care Cost Containment System
Ngozi Ezike, MD, Director, Illinois Department of Public Health

4 p.m. (ET) Thursday, Nov. 12, 2020

DOWNLOAD SLIDES

Results of a Five-State Community of Practice to Improve Medicaid Immunization Rates through Partnerships

October 5, 2020/in Policy Blogs, Featured News Home CHIP, CHIP, Chronic Disease Prevention and Management, Health Coverage and Access, Health Equity, Immunization, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by Rebecca Cooper, Jill Rosenthal and Ariella Levisohn

Faced with persistent disparities in vaccination rates among children and pregnant women, a five-state community of practice, coordinated by the National Academy for State Health Policy (NASHP), AcademyHealth and Immunize Colorado, formed interdisciplinary, cross-agency teams to address access and other challenges to reduce immunization gaps among low-income pregnant women and children. Their approaches and lessons learned can help states address current immunization disparities and be used when a COVID-19 vaccine is available.

Vaccines are a powerful and cost-effective tool to prevent diseases and save lives. According to research estimates, of 4.3 million infants born in 2009 in the United States, vaccines will prevent 40,000 deaths and 20 million illnesses over their lifetimes. Vaccinating children is also cost effective, saving $10.20 for every $1 invested in immunizations. In recognition of these benefits, states continue working to improve immunization rates and use multiple levers, including Medicaid programs, to promote full immunization coverage.

While the Vaccine for Children and Medicaid programs have reduced racial and ethnic disparities for women and children, disparities persist, especially in adult populations. According to a Centers for Disease Control and Prevention (CDC) report published in the Morbidity and Mortality Weekly Report, pregnant women enrolled in Medicaid are less likely to be vaccinated for the flu and diphtheria and pertussis (Tdap) compared to those with private insurance. Common barriers to reaching full immunization coverage include:

Access challenges, including geographic barriers and disparities in health insurance coverage;
Data challenges, including policy, legal, and technical limitations to integrating data between immunization information systems (IIS) and Medicaid information systems (MMIS); and
Policy challenges, including vaccine opt-out policies and optional participation in IIS.

To address these challenges and reduce immunization gaps among low-income pregnant women and children, NASHP, AcademyHealth, and Immunize Colorado coordinated efforts through a three-year CDC cooperative agreement to support states in implementing improvement strategies and policies. The project team convened a community of practice comprised of staff from Medicaid agencies, immunization programs, and IIS, in Colorado, Hawaii, Kentucky, Montana, and New Mexico. These interdisciplinary cross-agency teams worked together towards a shared public health goal of increasing immunization rates. A steering committee of state Medicaid and public health leaders, immunization-focused national organizations, and subject matter experts also provided expertise and guided efforts.

NASHP, AcademyHealth, and Immunize Colorado provided technical assistance in several key areas, including resources around IIS funding and sustainability, cross-agency collaboration, data infrastructure including IIS onboarding support, and provider and community outreach. Over the course of the project, the five states made improvements in those areas of work and developed fact sheets highlighting their successes. For example:

Hawaii and New Mexico strengthened their IIS infrastructure by applying for and receiving a 90 percent match rate through federal Health Information Technology (HITECH) administrative funding.
Kentucky and Montana onboarded new providers (e.g., pharmacists and non-pediatric immunizing health care practices) to their IIS to encourage vaccination of children and pregnant women.
Colorado, Hawaii, Kentucky, and New Mexico improved data-sharing and data analysis capabilities, creating documented memorandum of understanding (MOUs), data dashboards, and data matching between IIS and Medicaid data systems.
Two states enacted legislation to increase access to vaccinations: Hawaii required students entering seventh grade to receive the human papillomavirus (HPV), TDap and meningococcal vaccines (which affect more than 13,000 children per year), and Montana lowered the minimum age for which pharmacists may vaccinate children.
States also added immunization measures to state Medicaid value-based programs to capture and reward quality improvement.

Changes in State Medicaid and Children’s Health Insurance Program Measures and Incentives for Childhood and Adolescent Immunizations
State	2015 Measures and Incentives for Immunizations	2020 Measures and Incentives for Immunizations	Change?
Colorado	Managed Care Organization Performance Improvement Project (MCO PIP)	MCO tracking measure MCO performance measure	Yes
Hawaii	Medicaid performance measure	Medicaid performance measure
Kentucky	MCO-required Healthcare Effectiveness Data and Information Set (HEDIS) reporting measure	MCO-required HEDIS reporting measure
Montana	N/A	Patient-centered medical home (PCMH) measure Medicaid performance measure	Yes
New Mexico	MCO PIP	MCO tracking measure MCO performance measure	Yes

Data from NASHP’s State Strategies to Promote Children’s Preventive Services. Chart updated March 2020.

States worked towards their project goals of improving immunization rates for pregnant women and children by creating and strengthening partnerships between Medicaid and public health agencies. Stronger Medicaid and public health partnerships enable states to identify disparities and target additional outreach and interventions.

These state partnerships and system improvements ensure a foundation for future immunization efforts. States will be able to use this strong foundation for more efficient vaccine distribution, data tracking and reporting, communication, and provider outreach and engagement, and, these frameworks will be critical in a future dissemination of a COVID-19 vaccine.

As these states continue to implement their immunization strategies and navigate this new health landscape with the added challenge of COVID-19, NASHP, Academy Health, and Immunize Colorado will engage additional states in efforts to improve immunization systems through cross-agency collaboration, using the lessons from these five states to address disparities in immunization rates among children and pregnant women.

States Include Catch-up Routine Immunization Strategies in Back-to-School Planning

July 27, 2020/in Policy Hawaii, Michigan, Oregon, Texas Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Immunization, Maternal, Child, and Adolescent Health, Population Health /by Rebecca Cooper

As states consider strategies to reopen schools safely this fall, ensuring that children receive their appropriate, on-schedule vaccines continues to be an important safety and prevention strategy. Because the COVID-19 pandemic has dramatically reduced the volume of in-person children’s preventive care visits across the country – many providers have reported a 70 to 80 percent decrease in well-child visits with fewer children receiving immunizations – catching children up on missed routine immunizations is critical, regardless of whether schools offer in-person instruction.

The American Academy of Pediatrics states that, “existing school immunization requirements should be maintained and not deferred because of the current pandemic,” and according to a 2014 study, vaccines will prevent 40,000 deaths and 20 million illnesses over the lifetimes of US children born in 2009. As a result, many school districts are implementing strategies that include immunizations along with other health priorities, like social distancing, mask wearing, and increased hygiene measures, for students in their back-to-school plans.

The Centers for Disease Control and Prevention’s (CDC) priorities for the fall include catching children up on needed routine vaccinations and ensuring that adults and children get their annual flu shots to stay healthy and reduce the risk of coinfections and the burden on the health care system. CDC also recently released guidance to assist local public health agencies in establishing satellite vaccination clinics for routine vaccinations, including back-to-school immunizations and annual flu shots. Considering the immense pressures teachers and school administrators face as policymakers grapple with school reopening decisions, continuing to provide protection from preventable diseases is critical.

Keeping children protected from vaccine-preventable diseases is not contingent on in-person learning. States need to continue to plan for catch-up vaccinations even if states and school districts have not yet solidified their reopening plans amid rising national COVID-19 case counts, and children should have all necessary protections from vaccine-preventable diseases. However, because some states are requiring all schools to open, it is especially important to ensure there is a process for appropriate back-to-school vaccinations to be administered to keep children healthy. Several states and counties have already released back-to-school immunization plans:

Hawaii: Effective July 1, 2020, additional immunizations will be required for students entering childcare facilities or schools. By the first day of school, all students entering childcare or school in Hawaii must have either a completed health record form or an appointment already scheduled with a health care provider, as well as a completed tuberculosis (TB) clearance form. Students who have not completed the requirements will not be allowed to attend school until the requirements are met. The updated immunization requirements were enacted prior to the pandemic to conform with national recommendations and reflect what already existed as standard medical care in Hawaii. State officials chose to maintain this guidance despite uncertainty from COVID-19.
Michigan: Its Department of Health and Human Services (DHHS) is urging families to catch their children up on needed vaccines that were postponed during the COVID-19 pandemic. Michigan providers are implementing new procedures to ensure patients can come in for well-child visits and get caught up on immunizations, including the flu vaccine, in the fall. Additionally, bipartisan legislation was introduced that requires proof of vaccination before entering 12th grade to ensure an accurate immunization status for high school students, and directs the DHHS to adopt the CDC-recommended immunization schedule.
Texas: The state announced that school vaccination rules are in effect for the 2020-2021 school year that students should be up-to-date, or in the process of receiving their vaccinations, or have a valid exemption when school starts. Texas’ school vaccination rules are in effect regardless of where the education is received (on campus or via virtual learning).
Oregon County: Oregon county health Departments began scheduling 2020-2021 school year catch-up immunizations during the summer to help limit the number of individuals in provider offices receiving vaccines at any one time, and to help prevent running out of supplies, because the department is only able to place new vaccine orders once a month.

In the midst of an uncertain infectious disease climate, states continue to prioritize maintaining immunization rates, and states can use back-to-school immunization requirements as a tool to ensure timely vaccine catch-up. However, vaccine requirements are a contentious issue and state legislatures across the nation continue to debate this topic. Prior to the start of the COVID-19 pandemic, Colorado and Maine, for example, enacted new school entry immunization laws that created more stringent procedures for obtaining immunization exemptions. These states are working to prevent future outbreaks, considering the evidence that unvaccinated populations can lead to community outbreaks.

States will also need to consider strategies to ensure school-aged children will have equitable access to the COVID-19 vaccine when it becomes available. In Wisconsin, for example, both the state legislature and the Department of Health Services can add new vaccines, such as a potential new COVID-19 vaccine, to Wisconsin’s list of required vaccines for school children and children in childcare settings. Other states are taking preventive action to ensure they have a system in place for vaccine distribution when it is available. For example, New York amended a law authorizing licensed pharmacists to administer any approved vaccine for COVID-19 to include children between the ages of 2 and 18.

Schools are often under local jurisdictions and while considering federal guidance and local public health risk, most decisions will be made at the state and local levels. But, regardless of the variation, states have to make challenging decisions about reopening schools in the midst of the COVID-19 pandemic. One critical step they can take to ensure student’s health is prioritizing immunizations to ensure children are protected from preventable disease regardless of whether schools reopen in-person. The National Academy for State Health Policy will continue to monitor state back-to-school immunization policies, state efforts to keep children protected from vaccine-preventable diseases, and their implications for children.

This blog was written with support from the Centers for Disease Control and Prevention.

States Factor in COVID-19’s Impact on Immunizations and VBP Incentives

June 2, 2020/in COVID-19 State Action Center Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Immunization, Maternal, Child, and Adolescent Health, Population Health /by Rebecca Cooper

Because of the great public health value of childhood vaccines, state Medicaid programs have promoted value-based purchasing (VBP) programs as a lever through managed care and fee-for-service programs to reward providers that immunize a high rate of children, who make up about 55 percent of Medicaid’s managed care enrollees nationwide.

However, COVID-19 has greatly reduced the number of children and families making in-person, well-child office visits to receive their immunizations. This disruption threatens the progress that VBP has made in rewarding increased quality care, including boosting childhood immunization rates.

In response, the Centers for Medicare & Medicaid Services (CMS) recently issued relief guidance and flexibility to state hospitals, facilities, and providers that report various measures including immunization rates as part of their participation in VBP and quality reporting programs. CMS also announced it will disregard all costs associated with COVID-19 care when performing benchmark calculations, and that states may make similar changes for VBP arrangements in the Medicaid program.

Background

Medicaid programs have historically promoted childhood immunizations through various levers, including VBPs. Recent research shows that over half of state Medicaid agencies that contract with managed care organizations (MCOs) mandate payment reform, and as of July 2019, these MCOs provided care to about 69 percent of the total eligible Medicaid population.

To improve immunization rates, Medicaid offers various incentives in both MCO and fee-for-service arrangements. A March 2020 review by the National Academy for State Health Policy (NASHP) found that 46 states had measures or incentives to improve child immunization rates. Below are trends seen in state immunization programs:

Thirty-eight states changed their immunization measures and incentive programs between 2016 and 2020 – 36 states added new immunization measures and incentives while two states reduced their measures;
Nineteen states have immunization pay-for-performance measures tied to reimbursement;
Seven states have implemented immunization managed care measures after previously having an immunization performance improvement project (PIP); and
Twelve states adopted new immunization-related Healthcare Effectiveness Data and Information Set (HEDIS) measures, which are used to evaluate health plans.

Despite these strategies to maintain or increase immunization rates, evidence shows that immunization rates are decreasing. The pervasive fear of potential exposure to COVID-19 in doctors’ offices, as well as other social barriers, such as a lack of access to transportation, has resulted in fewer families taking their children for well-child or follow-up visits. In response, many states have relaxed telemedicine guidance to allow well-child visits to be conducted through telehealth. But because immunizations cannot be administered through telehealth, states are releasing guidance on follow-up visits for children to receive their immunizations.

State and Federal Governments Factor in the Impact of COVID-19

This major disruption in health care threatens the progress that VBP has made in improving the quality of care by rewarding positive changes and efficiency. CMS has recently issued relief guidance and flexibility to aid state hospitals, facilities, and providers that report their HEDIS and other pay-for-performance measures as part of quality reporting programs and VBP.

CMS has also announced that they will disregard all costs associated with COVID-19 care when performing benchmark calculations, and that states may make similar changes for VBP arrangements in their Medicaid programs. Few VBP arrangements currently address how emergency situations affect the quality of care or cost arrangements, but states may need to factor in this issue when executing future VBP contracts, to ensure providers are supported in administering appropriate levels of vaccinations, and to make sure children’s health is not at risk.

The National Committee for Quality Assurance (NCQA ), an organization that measures the quality of medical providers and health plans by analyzing their HEDIS data, has recommended that states continue reporting HEDIS data as usual. But, NCQA stated it will work with health plans whose ability to report data is compromised and make accommodations, and they indicated it abide by state data reporting decisions. It is essential for states to track their data accurately to inform their efforts to improve immunization rates, and track improvements in quality of care. Some states have also begun to issue their own guidance to providers on VBP payments despite potential changes in volume.

For example, MaineCare (Maine’s Medicaid program) has issued a bulletin acknowledging that providers who participate in VBP initiatives may have concerns about how changes in health care delivery will impact their performance in their alternative payment models, but that Maine Primary Care Provider Incentive Payments will be made on the existing schedule. July 2020 Primary Care Provider Incentive Payments cover a period of time not affected by COVID-19 and will be delivered as normal. January 2021 and July 2021 payments will be adjusted to exclude data from the impacted time period.

State strategies to fight the pandemic while incentivizing quality care and meeting the needs of their population continue to evolve. State and federal guidance related to VBP will be critical to ensure that increased immunization rates continue to be incentivized and health care delivery gains are maintained to keep children healthy now and after the immediate emergency subsides. NASHP will continue to track COVID-19 impacts on state health care delivery of immunizations and performance in alternative payment models.

This blog is supported by the Centers for Disease Control and Prevention.