INFLUENZA VACCINATION FOR SENIORS

Removing Financial and Geographic Barriers to Access

When baseline results are less than stellar, many plans invest in an intervention or two to improve their results. This plan tried to address as many barriers as possible. When it came to helping seniors get immunized against influenza, the plan learned that one size of intervention does not fit all.

In January 1995, a routine data analysis identified pneumonia as the eight most frequent discharge diagnosis experienced by this plan's members. Many cases of pneumonia are preceded by an influenza infection, and both of these diseases are significant causes of morbidity and mortality in the elderly. The plan decided to address this major health problem by measuring and improving the rate of influenza vaccination for its senior citizens.

The target population consisted of commercial and Medicare members 65 years of age or older who were continuously enrolled during the year. The measure used was the percentage of the population receiving an influenza vaccination (CPT-4 code 90724) during the year. The plan used administrative data from encounters and claims.

Data from 1994 showed a dismally low baseline vaccination rate 7.7%. After deeming the baseline performance unacceptable, the plan set a rate of 60% as its goal. Then, it began to formulate a strategy to attain this goal. A benchmark was not established by the plan for this initiative.

ENCOUNTER DATA This plan determined that capitated arrangements with providers may have made it impossible to record all vaccinations for influenza. Virtually all performance measures are influenced not only by the care delivered but also by the ability to report on that care. When rates seem impossibly low, strategies for improving a plan's data recording capabilities are required.

The plan's staff implemented interventions aimed at many potential barriers, including:

• Transportation to physician officers
• Cost of copayments
• The difficulty some seniors had in remembering the need for an annual flu shot
• Lack of knowledge about the need for influenza immunization

In the initial year, the plan educated both members and providers on the need for vaccinations with articles in the member and provider newsletters, and sent reminders to all members in the target population in the form of a personalized letter and follow-up postcards. The plan also began including information about the importance of influenza vaccinations in the new member materials sent to Medicare members at the time of enrollment.

The plan waived the visit copay for all influenza vaccinations received during the recommended immunization season, from September through December. Initially the plan had difficulty determining how to reimburse the practitioners for lost revenue from the copayments. After experimenting with several methods, the plan's staff settled on a process in which practitioners used preprinted forms. They completed these forms and submitted them along with their claims, which were then reimbursed at a higher rate.

To address transportation barriers, the plan investigated the use of alternate sites for vaccinations. They used hospitals, grocery stores, and group practice clinic sites. Contracting with a home health vendor, the plan staffed 106 sites on 30 different dates.

CONVENIENCE Perhaps the most demanding aspect of this activity was improving the convenience of immunizations for seniors. For instance, the plan found that hospitals were not the most popular sites for flu shot clinics. Handicapped parking spaces were often full, and seniors disliked walking long distances to the hospitals' vaccination sites.

The first remeasurement, based on 1995 data, demonstrated a rate of 34%, a significant improvement in performance.

Encouraged by this improvement, the plan continued with its strong interventions. The plan provided primary care physicians (PCPs) with lists of their patients who had been vaccinated during the previous year. PCPs were sent a form, indicating the date of immunization, that could be placed in the chart of members who received vaccinations at one of the plan-sponsored alternative sites. Practitioners also were given a comparison of their own vaccination rate to the plan's overall rate. The copay for flu shots was once again waived from September through December.

The second remeasurement, based on 1996 data, was encouraging: 44.9% of targeted members received an influenza vaccination. This improvement was statistically significant.

The plan continued its interventions:

• Continuing to inform PCPs of their targeted patients, vaccines given at alternate sites, and immunization rates
• Copayment waiver for influenza vaccinations from September through December
• Reminder cards
• Immunization clinics at alternate sites

The plan evaluated its progress using 1997 data and was disappointed to find a decrease in the rate of 41.5%.

In an attempt to determine the reason for this decrease and for any potential causes of under-utilization, the plan further analyzed the data by age and gender.

The hypothesis was that the frail elderly (85 years and older) would have lower vaccination rate because of their age, increased experience with chronic illness, and decreased mobility. This, however, did not turn out to be true. Members who were 85 years and older were actually slightly more likely to be vaccinated than their 65- to 74-year-old counterparts.

The plan also analyzed the data by provider group. It found that of the 17 largest provider groups, all but four were within 3% of the plan rate. In 1998, the plan contracted with a large outside vendor to provide and staff vaccination clinics at more than 400 area locations. It customized its reminder cards for several provider groups to encourage members to go to their PCP's office for influenza vaccination.

Since then the plan has expanded its barrier analysis. It is considering interventions targeting provider groups with poor rates and seniors who don't get annual immunizations.