The goal of this conference was to develop practical and feasible recommendations for actions that would improve childhood vaccination rates and help achieve the immunization goals of Healthy People 2010. In preparation for the break-out groups' work on these recommendations, 4 overarching issues were summarized: (1) barriers that impede the achievement of Healthy People 2010 immunization goals should be identified and prioritized; (2) the gathering and reporting of vaccination data should be standardized to improve the quality of clinical-decision support systems, immunization policies, and practices that rely on the data; (3) physicians should have the central role in determining the success of vaccination efforts; and (4) payment for vaccination services should be adequate to cover the cost of providing the service and should be consistent across payers. Reports from the break-out groups and subsequent discussions determined areas of agreement (mainly what needs to be achieved), but views differed regarding what needs to change, and how, to achieve the Healthy People 2010 immunization goals. The societal benefits of immunization accrue over time, but expenses must be paid by individuals or third parties in the present. Achieving the immunization goals set by Healthy People 2010 will provide immediate and long-term benefits in reduced morbidity; for children particularly, the additional years of their lives imply that the cost per year of life is even lower than that for adults. When children fail to receive age-appropriate vaccinations, the societal gains of preventable morbidity, excess mortality, avoidable medical care expenditures, and decreased productivity are jeopardized. Participants felt that underutilization of vaccines is multifactorial and that consistent improvements across all childhood groups will require changes by patients, providers, purchasers, and, especially, the federal government. Achieving national goals for childhood immunizations must occur within the context of a pluralistic, mixed public-private health-care delivery system. Private solutions for financing and administering vaccines require a foundation of public investments in infrastructure. Public-awareness campaigns, funding for registries, and the identification and dissemination of best office practices to reduce missed opportunities to vaccinate patients are appropriate public-sector responsibilities. The National Immunization Program, the Vaccines for Children program, the Assessment, Feedback, Incentives, and exchange of Information program, and the Clinical Assessment Software Application database are commendable federal government initiatives, as is encouraging the development of a networked, national vaccine registry. However, creation of a complex immunization registry requires federal funds because it transcends the financial responsibility and means of patients, providers, administrative-service organizations, and purchasers. The role of health insurance in preventive care must be reexamined. Insurance plans are inconsistent in the coverage, or the adequacy of the coverage, of vaccines and associated administrative costs. Although Healthy People 2010 immunization goals suggest that vaccines should be considered a core health-insurance benefit, current trends (eg, defined contribution rather than defined benefits, and consumer-directed health plans) are toward fewer rather than more employer-based health benefits. As individuals and their caregivers decide which services to obtain and which to forgo, copayments and deductible services can be adjusted to encourage vaccinations. Organized systems of care can be motivated to compete regarding the effectiveness of their immunization practices through incentives (eg, the National Committee for Quality Assurance and Health Plan Employer Data and Information Set report cards) and initiatives (eg, Pay for Performance). Insurers and employers will require demonstrated performance improvement beyond vaccine cost-effectiveness analyses as a condition for higher payments. Providers, on the other hand, are experiencing decreased payment (relative to the increased cost of providing services) and increased expectations and work-load. Vaccine payments are perceived to be inadequate for the product, for its administration, and, particularly, for existing single payments for combination vaccines.
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