Sustainability of school-located influenza vaccination programs in Florida

Abstract

Background: School-located influenza vaccination (SLIV) programs are a promising strategy for increasing vaccination coverage among schoolchildren. However, questions of economic sustainability have dampened enthusiasm for this approach in the United States. We evaluated SLIV sustainability of a health department led, county-wide SLIV program in Alachua County, Florida. Based on Alachua's outcome data, we modeled the sustainability of SLIV programs statewide using two different implementation costs and at different vaccination rates, reimbursement amount, and Vaccines for Children (VFC) coverage.

Methods: Mass vaccination clinics were conducted at 69 Alachua County schools in 2013 using VFC (for Medicaid and uninsured children) and non-VFC vaccines. Claims were processed after each clinic and submitted to insurance providers for reimbursement ($5 Medicaid and $47.04 from private insurers). We collected programmatic expenditures and volunteer hours to calculate fixed and variable costs for two different implementation costs (with or without in-kind costs included). We project program sustainability for Florida using publicly available county-specific student populations and health insurance enrollment data.

Results: Approximately 42% (n=12,853) of pre-kindergarten - 12th grade students participated in the SLIV program in Alachua. Of the 13,815 doses provided, 58% (8042) were non-VFC vaccine. Total implementation cost was $14.95/dose or $7.93/dose if "in-kind" costs were not included. The program generated a net surplus of $24,221, despite losing $4.68 on every VFC dose provided to Medicaid and uninsured children. With volunteers, 99% of Florida counties would be sustainable at a 50% vaccination rate and average reimbursement amount of $3.25 VFC and $37 non-VFC. Without volunteers, 69% of counties would be sustainable at 50% vaccination rate if all VFC recipients were on Medicaid and its reimbursement increased from $5 to $10 (amount private practices receive).

Conclusions and relevance: Key factors that contributed to the sustainability and success of an SLIV program are: targeting privately insured children and reducing administration cost through volunteers. Counties with a high proportion of VFC eligible children may not be sustainable without subsidies at $5 Medicaid reimbursement.

Keywords: Cost; Immunization; Influenza vaccination; Insurance; School health services; School-aged population.

Fig. 1

Billing outcomes of Alachua’s school-located influenza vaccination programs. Non-VFC = participants with no insurance, with an in-network private insurance company, or with an out-of-network insurance, VFC Doses = participants with Medicaid or meeting requirements for a VFC vaccine. ^a Percentages obtained by dividing by the total doses administered. ^b Claims reimbursed at >$0 (the average reimbursement from private insurers was $37.14 ($0.77 to $50.83). ^c Percentages obtained by dividing by the total Non-VFC doses administered. ^d Unbillable claims containing incorrect insurance policy information or were rejected from insurers because the participant was no longer covered. ^e Claims of participants meeting the “uninsured” VFC eligibility criteria, therefore unbillable. ^f Percentages obtained by dividing by the total VFC doses administered. ^g Claims reimbursed by Medicaid at $5. ^h Medicaid claims containing incorrect information or were rejected because the participants were no longer covered.

Fig. 2

Sustainability of school-located influenza vaccination programs with and without community support at varying vaccination rates. The vaccination rate among non-VFC and VFC groups are equal, however, the number of public and private kids immunized varied by county, based their insurance profile. County-specific health insurance data and enrollment were used to calculate the percentage of children in the non-VFC group (percentage of privately insured children multiplied by student enrollment) and VFC group (percentage of Medicaid insured children by student enrollment plus the percentage of uninsured children multiplied by student enrollment). Private school enrollment data for each county were excluded because data was unavailable. Fixed costs per student are: $1.54 (in-kind costs included) and $3.28 (all-inclusive aka in-kind costs not included). Variable costs per dose are: $3.41 (in-kind costs included) and $7.29 (in-kind costs not included). ^a $5 Medicaid reimbursement for 65% of VFC recipients (average reimbursement from VFC doses are $3.25). This is Alachua’s observed outcome with in-kind costs excluded. ^b $5 Medicaid reimbursement for 65% of VFC recipients (average reimbursement from VFC doses are $3.25). This is Alachua’s observed outcome with in-kind costs included. ^c $5 Medicaid reimbursement for 100% VFC recipients (assumption that all VFC recipients are covered by Medicaid). ^d $10 Medicaid reimbursement for 65% of VFC recipients. ^e $10 Medicaid reimbursement for 100% of VFC recipients (assumption that all VFC recipients are covered by Medicaid, and reimbursement amount was increased to $10, the Medicaid reimbursement amount for private medical providers).