A Model for SLIV Clinics: The Dollars and Sense of Billing Private Insurers for Immunization Services

State: WV Type: Model Practice Year: 2013

Mass vaccination of school-aged children may be the most efficient approach in reducing population-level influenza illness attack rates and potentially to substantially reduce the overall morbidity and mortality associated with influenza-related illness in the community. For this to be achieved, requires development of sustainable annual vaccination programs for children of all ages. The Kanawha-Charleston Health Department (KCHD) provides mass vaccination programs in schools to supplement vaccination services provided in the community. KCHD is located in Charleston, West Virginia; the city serves as the Kanawha County seat and the state capital. Kanawha County is the state’s most populous with nearly 200,000 residents. After operating successful school -located influenza vaccination (SLIV) clinics during the 2009 H1N1 pandemic, KCHD has developed a financially sustainable seasonal influenza vaccination program in schools by utilizing billing of third party payers. Since 2009, the health department has worked to improve the quality of the SLIV program and to build it into a model that other local health departments (LHD’s) can use. 2012 marks the 4th consecutive year that the Kanawha-Charleston Health Department has held SLIV clinics for children in public and private schools grades K – 12. The SLIV program targets over 28,000 students enrolled in 80 public and private schools in Kanawha County. This program has operated without any additional local, state, or federal funding. The health department has developed and implemented an immunization program that is not only completely self-sustaining, but also profitable. For the last two years NACCHO has awarded KCHD with Promising Practice Awards in recognition of the SLIV Program. Goals have been met that have shown increased influenza immunization rates in children and demonstrated reduced absenteeism in schools with higher influenza vaccinations. To ensure children were vaccinated during the 2009 H1N1 pandemic, KCHD partnered with the county school system and a local health center to implement school-based vaccination clinics as a delivery system for the H1N1 vaccination. The school based H1N1 vaccination program was totally funded through the Center for Disease Control and Prevention (CDC) Public Health Emergency Response (PHER) grant. The success of this campaign demonstrated that implementation of SLIV clinics can be an important venue to increase vaccination coverage for children. As the H1N1 pandemic ended, KCHD sought opportunities to build on the momentum of the H1N1 response. Planning included incorporating SLIV clinics into the health department’s 2010-11 Seasonal Influenza Vaccination Campaign. To make this program operational, KCHD had to overcome potential challenges including securing funding or a source of reimbursement to purchase vaccine and supplies, pay for staff, printing cost of information packets for parents, and other related expenses. The goal was to recoup upfront costs of vaccine, supplies, and staffing through billing of third party payers, including government and private insurances. The program was structured using the H1N1 SLV model with the addition of requesting insurance information on registration forms. Even though parents were asked to provide insurance information, the vaccination was offered to all children regardless of their insurance status. Each year, KCHD used proceeds from the previous Seasonal Flu Campaign to cover up-front costs and to subsidize vaccine costs for children without documented insurance coverage. In addition to creating a sustainable annual program, the primary objectives of this project were to implement SLIV clinics in 100% of schools in Kanawha County with enrollment greater than 50 while reducing student absence due to illness. Implementation began in October, 2010 when KCHD began vaccinating children through school based clinics and is continuing today. The success of this program depends on support from the local medical community, school administration, and most importantly, parents. Vaccination rates overall average 27% - 35%, with the highest rates continuing to be in elementary schools. Existing health department personnel oversees the entire management of this program. Partnerships with the Kanawha County Board of Education and participation of the Kanawha County school health system have essentially made this a win-win program for the community.
Responsiveness This practice addresses several significant issues critical to public health. Seasonal influenza remains a public health challenge due to the substantial health and economic burden throughout the world and the potential for rapid emergence and spread of new influenza virus strains. Influenza associated deaths in the United States can reach as high as 49,000 annually with an average of 200,000 hospitalizations per year. An estimated 10.4 billion is spent for related medical cost annually in the US. Mass vaccination of school-aged children may be the most cost and time effective approach in increasing influenza immunization coverage among this group. Recent studies have demonstrated that protection may extend beyond the school walls to prevent disease transmission to unvaccinated household contacts and community members By having the capacity to provide mass vaccinations through SLV clinics, we further enhance our emergency preparedness capabilities to provide mass vaccinations during a pandemic. Public health has a long standing commitment to increase vaccination coverage for children. The relatively short window of time in which annual influenza vaccinations should be administered increases the burden on private providers and creates lost work time for parents to take children to appointments. School-aged children are less likely to have routine preventive medical care which translates into lost opportunities for vaccinations. KCHD has collected four years of data which demonstrates the sustainability of the SLIV program. In order for public health departments to remain financially viable during transitioning to health reform it is a necessity that LHD’s have the capacity to bill private insurers for immunization services. Although many states have now implemented SLIV clinics, most offer the vaccine free of charge and rely on grants or community funding to cover vaccine and expenses. Since 2010, new health plans are required to cover preventive services, including vaccines which will greatly reduce uninsured and underinsured populations. CDC’s 317 vaccine funding will be reduced and states will no longer be allowed to use federal vaccines to provide free vaccines for insured individuals. Thus, CDC is now providing funding for state and local health departments to develop the capacity to bill health insurance plans for services provided to insured members. Billing private insurance is a relatively new concept for many public health departments. KCHD has encountered challenges with the billing processes for immunization services to privately insured persons. Four years of “lessons learned” experience will highlight some strategies that other LHD’s may use to circumvent many of the system pitfalls. As healthcare reform is executed, the need to secure reimbursement by private and public insurers is imperative for sustaining support for SLIV programs. Health departments interested in implementing immunization programs will benefit from strategies KCHD has implemented to reduce costs and improve operations. Innovation This practice is new to the field of public health Although many states have now implemented SLIV clinics, most are offering the vaccine free of charge and generally rely on grant or community funding to cover expenses. When funding sources are reduced or disappear entirely, the program cannot continue. The CDC has recently funded pilot projects in large health organizations to research the feasibility of billing third party payors for SLIV clinics, however, accurately assessing the results are difficult when the project itself relies on outside funding sources. The concept of a self sustaining influenza vaccination program led by local health departments, therefore, is relatively new. There is overwhelming support for school located influenza vaccine clinics including federal public health partners and the National Association of School Nurses (NASN). Not only are schools an ideal venue for immunizing children, research has proven that increasing influenza immunizations decreases absenteeism. There is a great deal of hesitation and concern over whether screening for children's insurance should be done. KCHD has documented evidence of support from the community including medical providers and parents. Since 2010, insurance providers are required to cover preventative services, including immunizations and public health providers need to consider reimbursable services as a revenue stream. NACCHO's toolbox includes a toolkit with resources for operating SLIV clinics but has very limited information on financing clinics and does not address sustaining SLIV clinics by billing government and private insurers. This practice discusses the concept of financing immunization clinics by billing insurance providers which increases the viability of the program and eliminates the dependence of this program on finding outside funding streams. KCHD has received NACCHO promising practice awards in 2011 and 2012 for different aspects of this process. This practice is being submitted in 2013 to demonstrate the process of using third party payors to sustain immunization programs.  
Global Immunization
Primary stakeholdersStakeholders in this practice include the Kanawha-Charleston Health Department Kanawha County Board of Education and School Health System. Parents serve as volunteer non-medical logistic support. Media outlets including newspaper, television stations, and radio provide coverage and advertisement for the SLIV clinics. Local government officials have also been very vocal in their support of the program. LHD roleKanawha-Charleston Health Department and Kanawha County Schools signed a Memorandum of Understanding (MOU) which designates the health department as the lead agency in the collaborative effort. The MOU sets forth the roles and responsibilities of each agency. In this agreement the health department is responsible for the up-front costs of the campaign, producing and printing materials for the parent packets, engaging media, training vaccinators and clerical support staff. KCHD is responsible for supplying vaccinators and support staff and completions of each SLIV clinic. KCHD has trained billing staff and utilizes students and seasonal personnel to supplement paid staff. School nurses are responsible for clinic schedules and logistics, review of medical screening forms and facilitating parent communication and may serve as vaccinators. The school system also covers school employees staffing costs. The school based health center operates independently of the health department. The Center operates school-based health service clinics in several middle and high schools and conducts the SLIV clinics in selected schools. In 2009 KCHD organized a community response to the pandemic through the organization of a H1N1 Taskforce with representatives from local government, hospitals, healthcare, first responders, education and businesses. When the pandemic ended, the taskforce was reorganized to serve as a Multi-“Agency Planning and Advisory Committee (MPAC) to assist in emergency preparedness planning, community health promotion, and policy advocacy. The committee has over 100 registered members that meet quarterly. The health department is a member of the Kanawha-Putnam Emergency Planning Committee )KPEPC) which serves Kanawha and neighboring Putnam county to bring together resources to create a common plan for managing community emergencies. State and local partners include partnering with the WV Division of Immunizations on initiatives to increase adolescent immunizations. MPAC provides another voice in the community and members are some of our strongest partners to advocate for public health practices and policies. Lessons learned Throughout the process, KCHD learned that being a community partner means being available and responsive to community needs. While it is impossible to avoid conflict indefinitely, working through such challenges as a team helps create a stronger final product. Another lesson learned was the importance of engaging partners early. A project like the school located vaccine clinics involves lots of people and moving parts, and laying the groundwork well in advance is vital during roll out. Finally, a very important lesson that KCHD has taken away from this project is to set clear objectives. Expectations may not always be the same for the other stakeholders in the group and having well defined goals ensures that everyone is on the same page. To increase seasonal influenza immunization coverage of children, KCHD implemented the SLIV program in 2010. Planning for SLIV clinics begins 6 months prior to implementation using a QI process. Data on school absences is collected from the Board of Education and analyzed by the Epidemiology Division. Clinics are held in all 80 public and private schools for grades K -12 between October and December. The clinics are advertised through the media and the school system utilizing telephone notification before packets are sent home with the students. Absenteeism data is requested and analyzed June - August.Please provide a succinct outline of some basic steps taken in implementing your practice.Meeting with Board of Education and School Nurses Develop MOU listing roles and responsibilities Develop and prepare packets during summer Hire and train seasonal nursing and clerical staff Conduct After Action Review Process immediately following completion of clinics. Include all partners in process review. Hold QI process meetings Order supplies early MRC volunteers and students are valuable resources for additional staff Have staff knowledgeable of insurance systems                               2010-11/ 2011-12 Itemized Expenses $71,000 /$ 69,500 (vaccine, staff, supplies) Amount Billed         112,300/ 116,900 Amount Collected    89,000 /84,000 Net Revenue          18,000 /14,500
Objective 1:Increase by 25% the number of children immunized for influenza through SLIV clinics. Objective 2:Decrease by 15% the number of children in Kanawha County Schools absent during active flu season. Objective 3:Increase by 10% the number of immunizations given in SLIV clinics covered by insurance payors.
Stakeholder CommitmentKanawha-Charleston Health Department has developed many partnerships in the community. Prior to starting SLIV clinics, the health department provided over 10,000 flu shots annually. After providing H1N1 immunizations through SLIV clinics during the pandemic, the school system was eager to assist with the school clinics and continuation of SLIV clinics is defined in the health department's 5 year strategic plan. SustainabilityKCHD is working to increase the number of insurance providers that have contractual agreements. The program has proved to be self-sustaining over the last 3 years and plans are underway to expand the immunization programs and services provided by the health department.