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Medicaid Agencies Cultivate Partnerships and Deploy Data to Bolster COVID-19 Vaccination Efforts
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.
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.
Restoring Federalism to Win the War against COVID-19
In its understandable urgency to build a long-needed national strategy on COVID-19, the Biden Administration faces a patchwork of state-based initiatives that can simultaneously support and confound a new national strategy. The previous Administration made states the frontlines against COVID-19 and, working with the US Centers for Disease Control and Prevention (CDC), states have built considerable infrastructure against the pandemic with the help of federal funding.
This work, however, reflects state variations in priorities and capacities, with many developing comprehensive approaches while others resisted a more fulsome approach to COVID-19 prevention. President Biden has made clear his intention to work collaboratively with states. He recognizes the considerable capacity that states now have in place, and knows his policies will require flexibility to accommodate the different state approaches now in operation. Importantly, the President’s $1.9 trillion stimulus package, which includes considerable funding to address Covid-19, still needs to be enacted by Congress and implemented by the federal government. State work necessarily continues as those political negotiations unfold.
Last week, the Biden Administration issued its National Strategy for the COVID-19 Response and Pandemic Preparedness, a comprehensive roadmap of actions and investments to address the pandemic head on. The National Academy for State Health Policy (NASHP) interviewed a diverse group of state officials from a cross section of states – red, blue, and purple, and large and small. This is a snapshot of those conversations – not a survey of all states – to take their pulse and hear how the transition to the Biden plan can be achieved to:
- Avoid redundancy and confusion between state and federal efforts;
- Build on investments made to state capacity to date; and
- Address the unique challenges in each state.
As they reflected on key provisions in the Biden plan, several common themes emerged, but underpinning their states’ operational issues is the urgent need for consistent, predictable, and adequate vaccine supplies.
Vaccine distribution and planning: State officials expressed frustration with the lack of consistent, reliable, and timely information about vaccine supplies, noting that the last-minute information about weekly vaccine allocations gives states little time to inform providers, determine how many doses can be administered that week, and inform the public. This leads to consumer confusion and may lead to vaccine resistance if consumers become increasingly frustrated as scheduled vaccination appointments are suddenly cancelled. Appreciating the manufacturing issues and challenge in keeping up with demand, state leaders nonetheless called for more advance notice so they can plan when doses are due, as opposed to the currently weekly announcements, and assurances that promised doses will arrive as scheduled. One state official likened it to declaring a moon shot and taking off without knowing how much fuel was available. State leaders believe more advance and reliable scheduling of doses will expedite getting shots into arms. Some urged the federal government to provide a more accurate and accessible dashboard of where vaccines are in the pipeline and when states can expect to receive them.
Vaccine prioritization: CDC, with input from its Advisory Council on Immunization Practices (ACIP), released guidance that prioritized frontline health care workers. Former Health and Human Services Secretary Alex Azar later included people 65 and older. States have all developed priority plans for their vaccine rollouts, but they have not consistently followed CDC guidance. States set their own priorities, some concluding that the federal recommendations were impractical because of limits in available dosages and the inflexibility of the federal guidance in addressing state-based priorities. Some states defined essential workers differently, some targeted those with chronic illnesses, while others noted the need to vaccinate families who live multi-generationally, rather than just the elder in the family. Some states opened vaccinations to all over age 65, and others limited to those over 70 or 75. (View each state’s vaccination priorities here.) Recognizing the disproportionate impact of COVID-19 on communities of color, some states have specifically identified people of color as a priority, but many have struggled to vaccinate them at equitable rates. Some officials noted that frontline health workers include many people of color, but others urged a more aggressive outreach to high-risk populations.
As more vaccine and supplies become available, federal priorities need to coordinate with state initiatives. Residents of a state may be in line for vaccines or expect to be next in line. If there is suddenly a different national prioritization, it may need to grandfather certain populations now in line for vaccines or consider allocating vaccines in such a way to maximize a seamless transition to new priority groups and assure a consistent national strategy.
Vaccine administration: Many states need a larger workforce to carry out their vaccination distribution plans and funding to expedite administration. Many have waived licensing and scope-of-practice rules to encourage more vaccinators, including approving dentists and veterinarians and recruiting volunteers from the ranks of retired health professionals. States are launching hotlines and dashboards to track vaccine availability and in some cases to schedule appointments. Scheduling, tracking, and managing vaccination programs will become an increasingly complex task as more vaccines are available and particularly as long as two doses are required.
States use different data systems, primarily CDC’s Vaccine Administration Management System (VAMS), the independent Prep MoD, and Immunization Information Systems, and each has its limitations. For example, VAMS does not allow a consumer to schedule a second appointment until the first is completed, which adds time and complexity to the process. The Biden Administration proposes to bolster data systems. Currently, only 21 of 46 reporting states and Washington, DC can track vaccines by race and ethnicity, complicating efforts to ensure equity in vaccine distribution. Timely efforts to streamline and speed appointment scheduling and reporting to immunization registries would be welcomed by many states.
State policymakers note that provider-based vaccination clinics are opening quickly and attract patients with health coverage, assuring providers receive reimbursement for vaccine administration. Health Resources and Services Administration funding is available for non-covered populations, but some states report that the billing system is burdensome. Providers, facing the pressure of getting shots in arms, may not be billing and reporting in a timely fashion, delaying efforts to document how many doses are in the pipeline and how many have been administered.
Mass vaccination sites: States, working with hospitals, health systems, clinics, and others are converting sports arenas, recreational centers, and even an unused racetrack to large-scale vaccination sites. Some are co-located with testing centers or food distribution sites. Systems are in place to register, schedule, and deliver vaccinations and hundreds of mass sites are operational within states. The Biden Administration has developed a draft plan, called Concept of Operations, to use the Federal Emergency Management Agency (FEMA) to establish clinics across the country and to authorize and fund states to use the National Guard to help staff the effort. Now under review by states, the plan would support implementation of mass clinics. However, some state officials admitted that was not where they need help right now. Others say mass clinics are in place but getting additional staff help would free up public health workers now staffing these clinics so they could seek out and vaccinate vulnerable populations. Mobile and small clinics could provide 250 doses a day, which would be useful in remote and rural areas. Close collaboration with states will be required both to build on current and planned clinic capacity and because it appears these FEMA-supported efforts will not receive additional vaccine allocations, but rather come from the state’s allocation.
As vaccine supply grows and mass clinics expand, states are contemplating the impact on claims volume and what issues might arise from such a massive, intensive activity, and the billing it will require.
Reaching vulnerable populations: Federal support may be best targeted to help states reach the homebound with limited or no internet or smart phone access, the homeless, uninsured, and those in rural areas. Special consideration needs to be given to populations of color disproportionately affected by COVID-19 and undocumented immigrants. The capacity to maintain vaccination sites on a 24/7 basis will expand access to those unable to come during normal business hours. State officials embraced the idea of FEMA spearheading home visits, particularly to homebound elders and those with disabilities for whom getting to a clinic would be challenging. Many of these individuals are enrolled in Medicaid and will require costly medical transportation if they must travel to a clinic for vaccination. Clinics in communities of color, staffed by trusted community workers, are important strategies designed to reach key populations. As statewide registration opens, some states are using data visualization heat maps to identify target populations and place clinics in appropriate locations. These and related strategies can inform federal initiatives so working with state officials they can effectively reach targeted populations.
Messaging: The Biden Administration plan includes a significant national education and publicity campaign to encourage vaccination and directly address vaccine hesitancy. A consistent national message delivered by trusted voices can significantly assist states, but collaboration will be required to understand the issues, minimize mixed messages, and effectively communicate with various populations, including those who are distrustful of large government vaccination efforts.
Preventing the spread of COVID-19: The Biden plan calls for expanded masking, testing, tracing, and data gathering and calls on governors to act. Presently, 41 states and Washington, DC have mask mandates in place and 20 have active social distancing requirements, although these are varied and subject to change. Most states limit capacity in indoor places and many have evening curfews for certain businesses.
However, enforcing mask mandates has been challenging as has expanding limits on indoor gatherings, particularly where people remove masks for eating or socializing. Whether the Biden Administration’s efforts to educate the public will result in more voluntary masking compliance remains a question and, as vaccines become more widespread, the importance of continued masking and distancing will require more aggressive explanation.
The Biden Administration, not yet a week-old, has moved with lightning speed to lay out a comprehensive and promising national strategy and to engage governors. Beyond vaccine availability and funding, two fundamental challenges confront its implementation.
First, over the last 10 months states have had the primary responsibility for addressing the COVID-19 crisis. They have met the challenge and established testing, tracing, treatment, and now vaccination strategies designed for that state. Any federal response now needs to contemplate how to minimize confusion and build on and integrate those states’ initiatives and the infrastructure they have established. An effective and long-awaited national strategy can prevent the state-to-state competition that was required to secure personal protective equipment and testing supplies early in the pandemic and instead develop a clear and well understood pathway to vaccinating all in the United States. These are logistical and political challenges – daunting to be sure – but resolvable with the partnerships and funding the Biden Administration has proposed, and if the supply chain to distribute vaccine becomes more reliable.
More demanding will be the individual state- policy variations designed to prevent the further spread of the pandemic, a compelling issue as viral mutations emerge. The challenges of controlling the disease and dealing with its economic fallout are real and test anew the concept of federalism.
NASHP has always supported the notion of states as innovators, launching experiments to try new ways to address problems. But the COVID-19 virus knows no national or state boundaries. At what point, then, does the urgency of our public health emergency override the authority of states? If the public information campaign based on scientific evidence led by the Administration to advance prevention strategies fail to secure compliance in states, conditioning federal funds on compliance may be the Administration’s only option to secure the prevention strategies required to protect the public’s health and win the war against COVID-19.
With Federal Guidance Evolving and Vaccine Supplies Uncertain, States’ COVID-19 Vaccine Distribution Plans Remain Works in Progress
This map and chart show how each state prioritized their populations in their vaccine distribution plans, submitted to the Centers for Disease Control and Prevention in October 2020.
As COVID-19 infections, hospitalizations and deaths soar and federal guidance evolves, states are finetuning their vaccine distribution plans as the US Food and Drug Administration (FDA) appears poised to approve a vaccine later this week. The timely, safe, and equitable distribution of the vaccines falls squarely on states and their providers, who are already stretched thin in dealing with the pandemic and need billions of federal funds to distribute the vaccines successfully in the months ahead.
Fueled by the challenges that confronted the distribution of testing supplies and personal protective equipment (PPE) earlier this year, and the knowledge that vaccine demand vastly exceeds current supply, states are developing distribution plans that will target high priority populations without clearly scheduled deliveries.
Supported by $200 million from the Coronavirus Aid, Relief, and Economic Security (CARES) Act for vaccination preparedness, state plans that addressed ordering, storage, handling, and distribution priorities were submitted to the Centers for Disease Control and Prevention (CDC) in October. Each state’s plan takes federal recommendations into consideration but are unique and reflect their workforce and population priorities.
CDC’s Advisory Committee for Immunization Practices (ACIP), which states historically rely on for vaccine guidance, will hold an emergency meeting to vote on their prioritization and vaccine recommendations after FDA votes to approve the vaccine later this week. However, if distribution begins 24 hours after FDA approval as planned, many states may receive the vaccine before ACIP issues recommendations.
How State Distribution Plans Vary
A National Academy for State Health Policy (NASHP) analysis finds that as of October, no two states have prioritized their populations in exactly the same way. While most state allocation plans are informed by federal guidance (CDC and/or NASEM), many have enhanced their plans based on recommendations from their own advisory boards or equity committees.
It is expected that as more information on vaccine doses and recommendations is released by federal panels, states may increase the specificity of their prioritization criteria.
Key differences between state distribution plans include:
- Number of phases: States vary in the number of phases they plan for allocation, from two phases (Maryland, Nebraska) to five phases (Montana, New York). Most states have three or four phases, with some of them subcategorized further into A, B, and C.
- Delineation of phases: Several states have not yet delineated which populations fall within each phase or have only identified Phase 1 target audiences. These states are either waiting for more federal guidance or are working with state task forces and committees to determine their phased approach.
- Estimates of numbers within each priority group: Roughly 40 percent of state plans report how many individuals are in each priority population. Others are still determining how many people they expect to vaccinate during each phase. These details could influence distribution plans as states would need adequate supply of vaccines for all individuals within a particular phase. States plan to use various GIS mapping techniques and other software to identify where priority populations live within the state.
- Targeting specific high-risk populations: Some states include racial and ethnic minority groups, tribal populations, and rural populations within a specific phase. Others plan to recruit vaccine providers serving rural or underserved areas early on, but do not specifically list these groups as a target population within any particular phase.
- Nuance of priority populations: States vary significantly in how they delineate target populations for each phase. For example, some states group all essential workers, or all inhabitants of congregate care facilities, in one phase. Others target distribution for specific populations with more nuance, like prioritizing people in congregate settings who are 65 or older over younger adults living in congregate facilities (like homeless shelters or prisons). This will place more responsibility on facilities and health care systems to decide on a nuanced distribution strategy during the initial distribution period.
Across the board, Phase 1 prioritizes vaccinating health care workers (HCWs). While all states prioritize HCW, some specifically identify who qualifies as an HCW (e.g., clinical staff vs. support staff who work in a medical facility, including janitorial and administrative staff). ACIP’s vote on Dec. 1, 2020, recommended states include residents of long-term care facilities (LTCF), such as skilled nursing facilities, nursing homes, and assisted living facilities, in Phase 1A of the distribution along with the previously recommended HCW. States who do not already list residents of LTCF in their initial phase will need to decide if they will incorporate ACIP’s recommendation into their distribution strategy and change their plans.
Not all states reported on all populations. Of the states that provided detailed information about how distribution would be prioritized within phases, NASHP found:
- Forty-two states included HCW in Phase 1A of distribution.
- Nineteen states included residents of LTCF in Phase 1A, and 21 states included LTCF residents in Phase 1B, six states designated that population in Phase 2 and one state designated for Phase 3.
- Six states (Delaware, Michigan, Mississippi, New Mexico, Pennsylvania, and Utah) further sub-prioritized distribution to HCW, by specifying paid and unpaid employees who are at highest risk of coming into contact with someone with COVID-19 to receive the vaccine first in Phase 1A, followed by other essential HCWs critical to maintaining the health care system, including administrative and janitorial staff, in Phase 1B.
- Ten states do not yet specify sub-prioritization of Phase 1 in their plans.
What is the initial vaccine distribution strategy?
Of those states that have issued guidance on how to sub-prioritize HCW, they have done so in three ways:
- Based their distribution on population. Allocation within the state will be proportional to the number of health care workers in the area.
- Designed distribution based on COVID-19 prevalence. Hospitals and facilities that have more cases of COVID-19 will get more doses of vaccine. In Utah, priority distribution will go to the top four hospitals treating the most COVID-19 patients, and in New York, HCW in areas with high COVID-19 prevalence are anticipated to receive the vaccine before HCW in areas with lower case rates.
- Use job responsibility. Certain HCWs will be prioritized over others. In Pennsylvania, the first doses will go to providers working in emergency departments, on inpatient floors, and in intensive care units.
In Kentucky, according to Gov. Andy Beshear, the first doses of the vaccines will be shipped to 11 hospitals. Kentucky is expecting to receive 38,025 doses of the Pfizer vaccine, and 76,700 doses of the Moderna vaccine. The Pfizer vaccine doses will be used to vaccinate 26,000 of the state’s nursing home residents and staff, and 12,000 more of the Pfizer doses will go to the frontline HCWs at greatest risk of exposure. California Gov. Gavin Newsom announced the state expects to receive 327,000 initial doses in mid-December, but the state is home to 2.4 million HCWs, with 1 million working in acute care hospitals and around 150,000 working in nursing homes. Tennessee anticipates receiving 56,550 doses of the Pfizer vaccine in the first immediate phase and the state plans to reserve one tray of 975 doses in case any vaccine spoils when shipped to facilities. Tennessee also plans to set aside 5 percent of its first shipment of the Moderna vaccine in case of spoilage (about 5,000 doses), with the rest of the doses going to each county health department.
Additionally, states will have to decide whether to save some of their initial doses for a second round of immunization for the first priority groups, or use their entire supply of vaccine and hope they are able to receive a second shipment in time to give HCWs their second dose within the required timeframe. Current guidance, as reflected in some state plans like Washington’s and Tennessee’s, suggest that the federal government plans to hold back doses and send a second shipment at a later date that is intended for second doses for these first individuals. The states do not know when to expect the next shipment of doses, or how many they will get in the follow up shipments.
How are states prioritizing other key populations?
State plans vary in specificity of phases for vaccinating other specific critical populations and are dynamic documents that are constantly updated. For states that did delineate, NASHP noted these trends:
- Teachers are a high-priority population. Twenty-two states plan to vaccinate teachers at some point during their Phase 1 distribution and 12 states list teachers in Phase 2.
- Incarcerated populations and correctional officers are usually in Phase 1 or 2. Nine states plan to vaccinate incarcerated people at some point in phase 1, 27 states plan to vaccine incarcerated people in Phase 2, and two states plan to vaccinate them in Phase 3. In contrast, 10 states plan to vaccinate correctional officers in Phase 1, and 13 states have plans to do so in Phase 2.
- Most states include individuals living in homeless shelters in phase 3. Eight states plan to vaccinate individuals living in homeless shelters at some point in Phase 1, 22 states plan to do so in Phase 2, and three states plan to do so in Phase 3.
What support do states need for successful distribution?
States have been planning for vaccine distribution for months, but acknowledge that their plans are working documents, and will need to be refined as more federal guidance and more information about the number of doses states can expect to receive become available. Key considerations include:
- ACIP’s upcoming vote following emergency use approval by the FDA regarding who should receive the vaccines and in what order, and then continued guidance as the situation evolves. As more data from the vaccines’ Phase 3 clinical trials become available, more changes might be made in distribution recommendations.
- Federal leadership and potential new funding to strengthen state and local distribution infrastructure as CARES Act funding expires on Dec. 31, 2020. States need to procure more personal protective equipment , set up socially distanced mass-vaccination sites, provide public information to encourage immunization and complete the logistics of delivering and tracking to priority populations.
- Other vaccines in the pipeline which may affect the timeline of the phases for each state, and equitable distribution of the vaccine.
While the vaccine will ultimately be available to everyone, states must make important policy decisions to ensure timely, ethical, and equitable distribution of the vaccine during initial phases when supply is limited
As states continue determining their priority populations and phased approaches, they anxiously await a stimulus package from Congress that includes much needed support for vaccine distribution. As the vaccine becomes available and states begin to roll out administration, NASHP will continue to track all aspects of the COVID-19 vaccine distribution process and engage with states to address challenges.
Support for this work was provided by Centers for Disease Control and Prevention.
Results of a Five-State Community of Practice to Improve Medicaid Immunization Rates through Partnerships
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 Factor in COVID-19’s Impact on Immunizations and VBP Incentives
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.
State Officials Work to Harness Medicaid as a Change Agent to Increase Immunization Rates
Despite vaccines’ effectiveness in preventing infectious diseases and strong public funding for childhood immunizations, vaccination rates among children living in poverty remain stubbornly lower than for children living above poverty and who are privately insured.
Recently, officials from several organizations, including the National Academy for State Health Policy (NASHP), AcademyHealth, and the Colorado Children’s Immunization Coalition, convened state officials and subject matter experts to identify strategies to improve immunization rates among Medicaid-enrolled children and pregnant women.
What Vaccine Benefits Do State Medicaid Programs Offer?
Recognizing their critical role in protecting public health, Medicaid covers all recommended vaccines for children and many state Medicaid programs do not charge pregnant women copayments for vaccinations in order to remove financial barriers. As a result of this publicly-funded initiative, immunization rates for Medicaid-covered children are higher than for children without health insurance, demonstrating the value Medicaid provides in overcoming socioeconomic barriers to provide essential health benefits.
| What is the Community of Practice? With support from a CDC cooperative agreement, NASHP and AcademyHealth, with support from the Colorado Children’s Immunization Coalition, are leading a Community of Practice to identify ways to improve immunization rates among Medicaid-enrolled children and pregnant women. These partners, participating states (CO, HI, KY, MT and NM), and experts will continue to convene the Community of Practice and share findings with other states seeking to increase immunization rates. |
Vaccination rates also vary by vaccination type. For example, Medicaid-covered newborns are vaccinated with the hepatitis B birth dose at higher rates than newborns covered by private insurance, demonstrating Medicaid’s effectiveness. Considering that Medicaid covers nearly half of all children in some states, this state program can build on its successes and serve as a change agent to make sure even more children receive crucial vaccinations.
Socioeconomic Disparities in Vaccination Rates Persist
Despite Medicaid’s success in boosting immunization rates, according to Centers for Disease Control and Prevention (CDC) data, socioeconomic disparities persist in vaccination rates among young children enrolled in Medicaid and pregnant women. Children living below poverty level, as well as Medicaid-enrolled and uninsured children, have significantly lower immunization rates for many vaccines compared to children living at or above poverty level and/or with private insurance. Similarly, Tdap (diphtheria, tetanus, and whooping cough) and influenza immunization rates are lower among pregnant women living below the poverty level and/or enrolled in public insurance programs.
CDC shared these findings recently when NASHP, AcademyHealth, and the Colorado Children’s Immunization Coalition gathered state officials and experts together to identify strategies to improve immunization rates among Medicaid-enrolled children and pregnant women.
Strategies to Narrow the Immunization Gap
Attendees noted that lower vaccination rates among Medicaid enrollees could result from many factors, including poor access to care or lack of provider recommendations. Meeting participants discussed several evidence-based interventions recommended by the Community Preventive Services Task Force to increase immunization rates among Medicaid beneficiaries. These include:
- Monitoring immunization status during home visits;
- Providing immunizations in school-based health clinics, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) settings, and other non-traditional venues; and
- Using standing orders for age-appropriate immunizations as defined by CDC during well-child visits.
Meeting participants also suggested leveraging relationships with managed care organizations and patient-centered medical homes, where applicable, to increase immunization rates and providing non-emergency medical transportation to help families adhere to well-child and prenatal appointments, where immunizations are commonly administered.
Meeting participants also identified use of data, primarily Immunization Information Systems (IIS), as a strategy to identify disparities and target immunization outreach. An IIS records immunization doses administered by participating providers and can provide both patient immunization histories for use by providers in a clinical setting. IIS can also collect data at the population level to guide actions to improve immunization rates.
However, attendees identified barriers to using IIS effectively at both the state and provider level, including:
- A lack of funding to support development and maintenance;
- Legal and technical barriers to data exchange;
- Data silos within and between agencies;
- Data-sharing challenges between electronic health records and other health information exchanges; and
- Onboarding and implementation hurdles.
Tools and websites are available to help states fully maximize their IIS and data-sharing capacities, and additional tools are under development.
States participating in the Community of Practice have employed successful strategies to reduce barriers to immunization among Medicaid participants. For example, Colorado has engaged in provider outreach and collaborated with WIC programs to share the immunization status of WIC clients. Montana developed performance-tracking measures for immunization rates and incorporated these into managed care organization contracts.
The Community Preventive Services Task Force also recommends the following evidence-based best practices to increase immunization rates:
- Reduce client out-of-pocket costs for vaccinations (Medicaid pays for vaccine administration, but low-income, uninsured patients must pay for administration of the free vaccines);
- Establish vaccination requirements for childcare, school, and college settings;
- Create client or family incentive rewards;
- Design client and provider reminder/recall systems;
- Encourage provider assessments and feedback;
- Generate provider reminders; and
- Create combination community- and health care system-based interventions.
As Community of Practice states identify strategies and lessons learned to improve vaccination rates among Medicaid-covered children and pregnant women, they will be shared nationally to support similar efforts in other states.
Photo Courtesy of the CDC
New Program Helps State Medicaid Programs Close an Immunization Disparity Gap
State Medicaid programs play a vital role in protecting public health by ensuring that children receive all of their recommended immunizations. If all children born in 2009 were fully immunized, for example, it would prevent 42,000 early deaths and 20 million cases of disease, while saving the country more than $13.5 billion in direct health care costs and $68.8 billion in total societal costs.
But a vaccination coverage gap remains for low-income children covered by Medicaid. In 2016, immunization rates for children enrolled in state Medicaid programs were 2.5 to 12 percent lower than among privately-insured children.
The United States has made great progress to reduce vaccine-preventable illnesses. Declines in these diseases and their associated health care costs are considered one of the greatest public health achievements of the last decade, and annual cases of many vaccine-preventable illnesses have dropped to historically low levels.
All children who are eligible for the Early and Periodic Screening, Diagnostic and Treatment benefit are covered for all vaccines recommended by the Advisory Committee on Immunization Practice. The Vaccines for Children (VFC) program provides immunizations at no charge to physicians’ offices and public health clinics that are registered as VFC providers.
While immunization rates for most recommended vaccines among children remain high overall, rates are often lower among children living in poverty. African American children also have lower immunization rates than white children. For example, in 2016 only 76.8 percent of African American children received at least four doses of the diphtheria, tetanus, and pertussis vaccine (DTaP) compared to 84.8 percent of white children. According to the US Centers for Disease Control and Prevention (CDC), only 65.5 percent of children living below poverty received the rotavirus vaccine, compared to 78.2 percent of children living at or above poverty.
These disparities point to a missed opportunity to both support children’s health and reduce health care costs.
The National Academy for State Health Policy and AcademyHealth, with support from the Colorado Children’s Immunization Coalition, will be working with states interested in improving Medicaid policies and outreach to increase immunization rates among low-income children and pregnant women. State Medicaid agencies, in partnership with their public health and immunization information system partners, will receive one-on-one consultations, opportunities to learn from other participating states, and annual in-person meetings. This project is funded through a CDC cooperative agreement.
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