Decline in physician referrals to health department clinics for immunizations

The role of vaccine financing


      Background: Physicians frequently refer children to health department clinics (HDCs) for immunizations because of high out-of-pocket costs to parents and poor reimbursement for providers. Referrals for immunizations can lead to scattered care. In 1994, two vaccine financing reforms began in New York State that reduced patient costs and improved provider reimbursement: the Vaccines for Children Program (VFC, mostly for those on Medicaid and uninsured) and a law requiring indemnity insurers to cover childhood immunizations and preventive services.
      Objective: To measure reported changes in physician referrals to HDCs for immunizations before and after the vaccine financing reforms.
      Design: In 1993, a self-administered survey measured immunization referral practices of primary care physicians. In 1997, we resurveyed respondents of the 1993 survey to evaluate changes in referrals.
      Setting/ Participants: Three hundred twenty-eight eligible New York State primary care physicians (65% pediatricians and 35% family physicians) who responded to the 1997 follow-up immunization survey (response rate of 82%).
      Results: The proportion of physicians reporting that they referred some or all children out for immunizations decreased from 51% in 1993 to 18% in 1997 (p<0.001). In 1997, physicians were more likely to refer if they were family physicians (28% vs. 13%,p<0.01), or did not obtain VFC vaccines (29% vs. 13%,p<0.001). According to physicians who referred in 1993, decreased referrals in 1997 were due to the new insurance laws (noted by 61%), VFC (60%), Child Health Plus (a statewide insurance program for poor children, 28%), growth in commercial managed care (23%), Medicaid managed care (19%), and higher Medicaid reimbursement for immunizations that is due to VFC (18%). For physicians noting a decline in referrals, the magnitude of the decline was substantial—60% fewer referrals for VFC-eligible patients and 50% fewer for patients eligible under the new insurance law.
      Conclusions: Vaccine financing reforms decreased the proportion of physicians who referred children to HDCs for immunizations, and may have reduced scattering of pediatric care.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Orenstein W.A
        • Atkinson W
        • Mason D
        • Bernier R.H
        Barriers to vaccinating preschool children.
        J Health Care Poor Underserved. 1990; 1: 315-333
        • Hinman A.R
        What will it take to fully protect all American children with vaccines?.
        Am J Dis Child. 1991; 145: 559-562
        • Lieu T.A
        • Smith M.D
        • Newacheck P.W
        • Langhorn D
        • Venkatesh P
        • Herradora R
        Health insurance and preventive care sources of children at public immunization clinics.
        Pediatrics. 1994; 93: 373-378
        • Hueston W.J
        • Mainous A.G
        • Palmer C
        Delays in childhood immunizations in public and private settings.
        Arch Pediatr Adolesc Med. 1994; 148: 470-473
        • Santoli J
        • Szilagyi P.G
        • Rodewald L.E
        Barriers to childhood immunizations.
        Pediatr Ann. 1998; 27: 366-374
        • Holl J.L
        • Szilagyi P.G
        • Rodewald L.E
        • Byrd R
        • Weitzman M
        A profile of uninsured children in the United States.
        Arch Pediatr Adolesc Med. 1995; 149: 398-406
      1. Rodewald LE, Shiuh T, Zell E, Dietz V, Szilagyi PG. Health insurance and underimmunization: lessons from the 1991 National Health Interview Survey (NHIS). Poster presentation at the 1995 APA/SPR/APS Annual Meeting, San Diego, CA, May 8, 1995.

        • Zimmerman R
        • Janosky J
        Immunization barriers in Minnesota private practices.
        Fam Pract Res J. 1993; 13: 213-224
        • Schulte J.M
        • Brown G.R
        • Zetzman M.R
        • et al.
        Changing immunization referral patterns among pediatricians and family practice physicians, Dallas County, Texas, 1988.
        Pediatrics. 1991; 87: 204-207
        • Wright J.A
        • Marcuse E.K
        Immunization practices of Washington state pediatricians—1989.
        Am J Dis Child. 1992; 146: 1033-1036
        • Ruch-Ross H.S
        • O’Connor K.G
        Immunization referral practices of pediatricians in the United States.
        Pediatrics. 1994; 94: 508-513
        • Bordley W.C
        • Freed G.L
        • Garrett J.M
        • Byrd C.A
        • Meriwether R
        Factors responsible for immunization referrals to health departments in North Carolina.
        Pediatrics. 1994; 94: 376-380
        • Centers for Disease Control and Prevention
        Physician vaccination referral practices and Vaccines for Children—New York, 1994.
        MMWR Morb Mortal Wkly Rep. 1995; 44: 3-6
        • Zimmerman R.K
        • Bradford B.J
        • Janosky J.E
        • Mieczkowski T.A
        • DeSansi E
        • Grufferman S
        Barriers to measles and pertussis immunization.
        Am J Prev Med. 1997; 13: 89-97
        • Fairbrother G
        • Hanson K.L
        • Butts G
        Medicaid managed care in New York.
        J Public Health Manag Pract. 1996; 2: 59-66
      2. Szilagyi PG, Rodewald LE, Humiston SG, et al. Immunization practices of primary care physicians in the United States. (See reference #11 for manuscript from this study.) Presentation at the 1993 APS/SPR Annual Meeting, Washington, DC, May 5, 1993.

        • Robinson C.A
        • Evans W.B
        • Mahanes J.A
        • Sepe S.J
        Progress on the childhood immunization initiative.
        Public Health Rep. 1994; 109: 593-600
        • Wood D.L
        • Halfon N
        The impact of the Vaccine for Children’s program on child immunization delivery.
        Arch Pediatr Adolesc Med. 1996; 150: 577-581
        • Fairbrother G
        • Friedman S
        • Hanson K.L
        • Butts G
        Effect of the Vaccines for Children program on inner-city neighborhood physicians.
        Arch Pediatr Adolesc Med. 1997; 151: 1229-1235
      3. New York State Department of Health. NYS immunization update. : New York State Health Department, Fall 1994.

        • Budetti P.P
        Health reform for the 21st century? It may have to wait until the 21st century.
        JAMA. 1997; 277: 193-198
        • Mariner W.K
        State regulation of managed care and the Employee Retirement Income Security Act.
        N Engl J Med. 1996; 335: 1986-1991
        • Szilagyi P.G
        • Rodewald L.E
        • Humiston S.G
        • et al.
        Immunization practices of pediatricians and family physicians in the United States.
        Pediatrics. 1994; 94: 517-523
        • Zimmerman R.K
        • Schlesselman J.J
        • Baird A.L
        • Mieczkowski T.A
        A national survey to understand why physicians defer childhood immunizations.
        Arch Pediatr Adolesc Med. 1997; 151: 657-664
        • Zimmerman R.K
        • Medsger A.R
        • Ricci E.M
        • Raymund M
        • Mieczkowski T.A
        • Grufferman S
        Impact of free vaccine and insurance status on physician referral of children to public vaccine clinics.
        JAMA. 1997; 278: 996-1000
      4. Rodewald L, Maes E, Coronado V, et al. Penetration of the Vaccines for Children program (VFC) among providers for preschool immunizations: results from the 1997 National Immunization Survey (NIS) Provider Record Check. 32nd National Immunization Conference, conference abstracts. Washington DC: Department of Health and Human Services, 1998:139.

      5. Rodewald L, Maes E, Coronado V, et al. Medical home and provider specialty of preschool immunization providers: results from the 1997 National Immunization Survey. 32nd National Immunization Conference, conference abstracts. Washington DC: Department of Health and Human Services, 1998:117.

      6. Schaffer S, Szilagyi P, Shone L, Humiston S. Adolescent immunization practices: a national survey of U.S. plenary presentation at the 1998 APA/SPR/APS national meeting, New Orleans, LA, May 1998.

        • U.S. Dept. of Health and Human Services
        Standards for pediatric immunization practices. U.S. Department of Health and Human Services, Washington, DC1992
      7. Szilagyi PG, Bordley WC, Vann JC, Kraus RM, Chelminski A, Margolis P. The effectiveness of patient reminder/recall interventions on immunization rates: a critical review of the literature. 32nd National Immunization Conference, conference abstracts. Washington DC: Department of Health and Human Services, 1998:136.

      8. Rodewald LE, Szilagyi PG, Humiston SG, et al. The effects of an outreach-based recall system and a policy to reduce missed immunization opportunities on immunization coverage and primary care. Pediatrics (In Press).

      9. Shefer A, Briss P, Rodewald L, et al. Improving immunization coverage rates: an evidence-based review of the literature. Epidemiol Rev (In press).

        • Margolis P.A
        • Lannon C.M
        • Stevens R
        • et al.
        Linking clinical and public health approaches to improve access to health care for socially disadvantaged mothers and children. A feasibility study.
        Arch Pediatr Adolesc Med. 1996; 150: 815-821
      10. Szilagyi PG, Humiston SG, Shone LP, Barth R, Kolasa MS, Rodewald LE. Reduction in vaccinations delivered by health department clinics: impact of vaccine financing? Am J Public Health (in press).

        • Centers for Disease Control and Prevention
        National, state, and urban area vaccination coverage levels among children aged 19–35 months—United States, 1997.
        MMWR Morb Mortal Wkly Rep. 1998; 47: 547-554