Department of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
PHYSICIAN  PARTICIPATION  IN THE

VACCINES  FOR CHILDREN  PROGRAM

. 
JUNE  GIBBS  BROWN 
Inspector  General 
JUNE 1995 
awM-93-oo320  OFFICE  OF INSPECTOR  GENERAL 
The  mission of the  Office of Inspector  General  (OIG),  as mandated  by Public  Law 95-452, as 
amended,  is to protect  the  integrity  of the Department  of Health  and Human  Services (HHS) 
programs  as well as the  health  and welfare  of beneficiaries  served  by those  programs.  This 
statutory  mission  is carried  out  through  a nationwide  network  of audits,  investigations,  and 
inspections  conducted  by three  OIG  operating  components:  the  Office of Audit  Services, the 
Office of Investigations,  and the  Office of Evaluation  and Inspections.  The  OIG  also informs 
the  Secretary  of HHS  of program  and management  problems  and recommends  courses  to 
correct  them. 
OFFICE  OF AUDIT  SERVICES 
The  OIGS  Office of Audit  Setvices  (OAS)  provides  all auditing  services for HHS,  either  by 
conducting  audits with its own audit  resources  or by ovemeeing  audit work done  by others. 
Audits  examine  the  performance  of HHS  programs  and/or  its grantees  and contractors  in 
carrying out  their  respective  responsibilities  and are intended  to provide  independent 
assessments  of HHS  programs  and operations  in order  to reduce  waste,  abuse,  and 
mismanagement  and to promote  economy  and efficiency throughout  the  Department. 
OFFICE  OF INVESTIGATIONS 
The  OIGS Office of Investigations  (01)  conducts  criminal, civil, and administrative 
investigations  of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of 
unjust  enrichment  by providers.  The  investigative  efforts  of 01  lead to criminal  convictions, 
administrative  sanctions,  or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud 
control  units which investigate  and prosecute  fraud  and patient  abuse  in the Medicaid  program. 
OFFICE  OF EVALUATION  AND  INSPECTIONS 
The  OIGS  Office of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and 
program  evaluations  (called  inspections)  that  focus on issues of concern  to the  Department, 
the  Congress,  and the  public.  The  findings and recommendations  contained  in these  inspection 
reports  generate  rapid,  accurate,  and up-to-date  information  on the  efficiency, vulnerability, 
and effectiveness  of departmental  programs. 
OEIS Atlanta  Regional  Office prepared  this report  under  the  direction  of Jesse  J. Flowers, 
Regional  Inspector  General  and Christopher  Koehler,  Deputy  Regional  Inspector  General. 
Principal  OEI  staff included: 
REGION  HEADQUARTERS  OTHER  REGIONS 
Betty  Apt,  Team  Leader  Mark  Ihshat,  SC.D.  Suzanne  Johnson,  Chicago 
Jackie  Andrews,  Project  Leader  Ann  OConnor  Carolyn  Neuwirth,  Dallas 
Josiah  Townsel  Michael  Sullivan, Boston 
Tammy Bonney 
For  additional  copies  of this report,  please  contact  the  Atlanta  Regional  Office  at 404-331-
4108.  Department of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
PHYSICIAN  PARTICIPATION  IN THE

VACCINES  FOR CHILDREN  PROGRAM

.  fJi SERVIC&$ 
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4*daa OEI-04-93-0032(-J  EXECUTIVE  SUMMARY

PURPOSE 
To identify  issues  affecting  physician  participation  in  the  Vaccines  for  Children 
program. 
BACKGROUND 
The  Public  Health  Sewice  (PHS)  launched  a major  initiative  to  help  increase 
immunization  levels  for  2-year-olds.  Rates  for  the  complete  vaccine  series  increased 
from  about  50 percent  in 1991 to 66 percent  in the  first quarter  of 1994.  However, 
the  goal  is to reach  90 percent.  One  part  of the  PHS  initiative  is the  recently  enacted 
Vaccines  for Children  program  (VFC)  which  allows the  Federal  government  to 
purchase  vaccines  from  manufacturers  and  provide  the  vaccines  free  to physicians  who 
participate  in the  program.  Participating  physicians  can  use the  free  vaccines  to 
immunize  children  enrolled  in Medicaid,  Native  American  children,  Alaskan  Native 
children,  and  children  without  insurance.  Children  who have  insurance  but  the 
insurance  does  not  cover  immunizations  (underinsured  children)  are  also eligible  for 
VFC  program  vaccines,  but  only at Federally  Qualified  Health  Centers  or Rural 
Health  Clinics. 
Prior  to the  VFC  program,  12 States  were  providing  free  vaccine  to private  physicians 
to immunize  all children  in their  States.  The  States  are  commonly  referred  to as 
universal  States.  Most  universal  States  had  a 90 percent  or more  physician 
participation  rate. 
The  Centers  for Disease  Control  and  Prevention  (CDC)  asked  for assistance  from  the 
office  of Inspector  General  to identify  and  describe  barriers  to physician  participation 
in the  VFC  program.  We  conducted  this study in response  to that  request.  To 
identi~  issues that  affect  physician  participation  in an immunization  program,  we 
surveyed  669 physicians  practicing  in five States  that  were  already  providing  free 
vaccines  to private  physicians  to immunize  all children  in their  States.  To  put 
physician  responses  in context  with their  State  policies,  we sumeyed  immunization 
program  officials  in 11 of the  12 universal  States.  We then  interviewed  immunization 
program  officials  from  21 non-universal  States.  We  gathered  our  data  in August  and 
September  1994, the  two months  immediately  preceding  the  programs  start-up  date, 
FINDINGS 
Paperwork requhments  could dikcoumge some physkians  @m  pamtipting  in the WC 
P~ 
Fifty-two  percent  (135 of 260) of the  physicians  we surveyed  said paperwork 
requirements  in their  universal  State  programs  were  excessive.  However,  their 
i  universal  programs  only required  one  form.  Under  the  VFC  program,  physicians  have 
to complete  three  one-page  forms.  Sixteen  percent  of the  physicians  we surveyed  said 
they  do not  expect  to enroll  in the  VFC  program  due  to excessive  paperwork 
requirements.  Physicians  also said two forms,  Provider  Profile  Form  and  Patient 
Eligibility  Screening  Record,  provide  unreliable  information. 
Ii  vaccine deliwy  systermcod  dhcoumge  physichn  participation 
Thirty-eight  percent  (38 of 101) of the  physicians  from  States  with  drop  points  and  31 
percent  (49 of 159) of the  physicians  from  States  with direct  delivery  systems 
complained  about  the  efficiency  of their  State  delivery  systems.  If physicians 
participating  in the  VFC  program  experience  similar  vaccine  delivery  problems,  they 
may drop  out  of the  VFC  program. 
Luck  of vaccine &livery  systems in some  States  h.  physician partic@ation 
According  to VFC  legislation,  Federal  funds  are  to finance  delivery  of program 
vaccines.  However,  only one  vaccine  manufacturer  would  agree  to a delivery  contract 
at the  federally  capped  vaccine  price.  As a result,  no Federal  delivery  system  has 
been  established,  and  CDC  continues  to  explore  other  delivery  options.  Thirty-five 
States  have  established  their  own delivery  systems  for private  providers,  and  at least 
ten  of the  remaining  fourteen  States  reported  they plan  to do so this year.  All States 
are  delivering  vaccines  to the  public  sector. 
Nwly  emablirhed maxiiwm allbwabli  vaccine a&nh&ration  fees for physicians  could 
help overcome  a barrier to physiciizn pdcipatim 
Prior  to the  VFC  program,  the  fees  States  allowed  physicians  to charge  parents  for 
administering  State-purchased  vaccines  discouraged  some  physicians  from  participating 
in universal  States.  To  illustrate,  25 percent  (64 of 260) of the  physicians  we surveyed 
said the  fees  States  allowed  them  to charge  were  inadequate.  For  the  VFC  program, 
the  Health  Care  Financing  Administration  established  significantly  higher  fees  that 
physicians  can  charge  parents  for  administering  vaccine.  The  new rates  are 
comparable  to what  physicians  were  charging  parents  to administer  privately-
purchased  vaccines.  Thus,  the  fees  should  not be  a barrier  to physician  participation 
in the  VFC  program. 
RECOMMENDATIONS 
The  CDC  should  continue  to develop  an efficient  and  reliable  vaccine  accountability 
mechanism.  The  CDC  officials said they  are  presently  reexamining  other  ways to 
obtain  information  intended  to be  provided  by the  provider  profile.  We  encourage 
CDC  to continue  this effort,  and  also examine  the  efficacy  of the  Patient  Eligibility 
Screening  Record  in universal  States. 
ii  The  CDC  should  continue  to explore  alternative  delivexy systems  and  should  examine 
the  efficiency  of both  drop-point  and  direct  delivery  systems.  Physicians  we surveyed 
described  problems  with both  types  of delivery  systems. 
AGENCY  COMMENTS 
The  Assistant  Secretary  for Health  commented  on our  draft  report  and  concurred  with 
our  recommendations.  He  expressed  CDCS concerns  that  the  accountability  system 
for the  VFC  program  balance  the  need  for  accountability  with  the  need  for a system 
that  encourages  physician  participation  and  reported  that  CDC  is continuing  to 
develop  accountability  systems.  Further,  he stated  that  CDC  is committed  to 
establishing  a delivery  system  for States  who  do not  choose  to deliver  vaccines 
themselves. 
The  Assistant  Secretary  for Health,  the  Health  Care  Financing  Administrator,  and  the 
Assistant  Secretary  for Planning  and  Evaluation  provided  additional  points  of 
clarification  and  technical  comments  which we responded  to by editing  portions  of the 
report. 
... 
111  TABLE  OF  CONTENTS 
PAGE 
=KxJmvE  suMMARy 
-OIXKIIO.
N. .  ...............  ............................ 
...1 
FINDINGS 
Paperwork  Requirements  . . . . . . . . . . . . . . . . . . . .
. . . . . . ..,.OO
 . . . . . . . . . . .  6

Inefficient  Vaccine  DeliveVSystems  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

Lack  of Vaccine  DeliveVSystems  In Some  States  . . . . . . . . . . . . . . . . . . . . . . . .  9

. .

Newly Established  Maximum  Alowable  Vaccine 
Administration  Fees  . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .  9

RE~MMENDmoNs  .  . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
...11

APPENDICES 
Criteria  for Selecting  States  For  Physician  Sumey  . . . . . . . . . . . . . . . . . . . . . . . .  A-1

Physician  Enrollment  Form,  Protider  Profile  Form,  and  Patient

Eligibility  Screening  Record  . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . .-.$O
 .  B-1

Vaccine  Usage  Report  . . . . . . . . . . . . . . . . . . . . . . 
. . . . . . . . . . . . . . . . . . . . . .  c-l 
Maximum  Vaccine  Administration  Fees  By State  . . . . . . . . . . . . . . . . . . . . . . . .  D-1

Agency  Comments  . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . ..O  E-1
 INTRODUCTION 
PURPOSE 
To  identify  issues affecting  physician  participation  in the  Vaccines  for Children 
program. 
BACKGROUND 
Millions  of American  children  are  at risk of severe  illness and  possible  death  from

childhood  diseases  such  as measles,  mumps,  rubella,  polio,  diphtheria,  pertussis,

tetanus,  hemophilus  b influenza,  and  hepatitis  B.  The  Advisory  Committee  on

Immunization  Practices  and  the  American  Academy  of Pediatrics  regularly  issue

guidelines  to health  care  providers  on scheduling  childhood  immunizations.  They

currently  recommend  that  all children  complete  a schedule  of vaccinations  by 18

months  of age that  includes  four  doses  of diphtheria,  tetanus,  and  pertussis  (DTP)

vaccine;  three  doses  of oral  poliovirus  (OPV)  vaccine;  one  dose  of measles,  mumps,

and  rubella  (MMR)  vaccine;  and  a complete  series  of Hemophilus  influenza  type b

vaccine.  In November  1991, the  Advisory  Committee  also recommended  three  doses

of hepatitis  B vaccine.

Between  1989 and  1991, several  major  outbreaks  of measles  refocused  Federal

attention  on childhood  immunizations.  The  number  of measles  cases  increased  from

approximately  3,400 cases  in 1988 to 28,000 cases  in 1991.  In response  to this concern

and  the  need  to develop  a sustainable  system,  PHS  launched  the  Childhood

Immunization  Initiative  (CII).  The  CII  is a comprehensive  approach  to  increase

immunization  levels  for  children  under  the  age  of two.  A  major  goal  of the  initiative

is to  increase  immunization  levels  for  two-year-old  children  to  at  least  90 percent  for

the  most  critical  doses  in  the  vaccination  schedule  by  1996.  The  initiative  would

achieve  this  goal  by improving  immunization  delivery  services,  increasing  community

participation,  educating  parents,  monitoring  disease  and  vaccination  coverage,

improving  vaccines  and  vaccine  use, and  reducing  the  cost of vaccines.

In  1991, the  number  of children  two years  of age who had  completed  the

recommended  immunization  schedule  was only about  50 percent.  In  1992, this had

increased  to 55 percent.  In  1993, the  immunization  level had  increased  to 67 percent.

In the  first  quarter  of 1994, the  rate  changed  slightly to 66 percent.  However,  this is

still far below  the  national  goal  of 90 percent  for the  complete  series  by the  year  2000.

. 
The Adviso~  Committee  on Immunization  Practices  is composed  of representatives  from 
Federal  and State  health  agencies,  medical  schools,  and associations  representing  various  health  groups. 
1  Vaccines fm  Children Rqgmm 
To reduce  the  cost of vaccines  to parents  (one  of the  goals  of the  CII),  Congress

authorized  the  Vaccines  for  Children  program  (VFC)  as part  of the  Omnibus  Budget

Reconciliation  Act  (OBRA)  of 1993.  The  VFC  program  allows the  Federal

government  to purchase  vaccines  from  manufacturers  at  discounted  prices  and  provide

the  vaccines  free  to physicians  who participate  in the  program.  Participating

physicians  can use  the  free  vaccines  to immunize  children  enrolled  for Medicaid,

Native  American  children,  Alaskan  Native  American  children,  and  children  without

insurance.

Children  who have  insurance  but  the  insurance  does  not  cover  immunizations

(underinsured  children)  are  also eligible  for VFC  program  vaccines,  but  only at

Federally  Qualified  Health  Centers  (FQHCS)  or Rural  Health  Clinics  (RHCs)~

Many  State  oi%cials have  expressed  concern  that  such  a policy would  create  a barrier

to underinsured  children  getting  immunized.  They  are  concerned  that  if physicians

refer  underinsured  children  to FQHCS  or RHCS for immunizations,  an opportunity  to

immunize  is lost.  Underinsured  children  will go to a private  physicians  office  for

other  health  care  because  they have  insurance  coverage.  When  this happens,  the

physician  has  an opportunity  to screen  the  childs immunization  status  and  immunize

the  child  on the  spot.  However,  if the  physician  refers  the  child to a FQHC  or RHC

for immunizations,  the  parent  may not  follow-through  with or may delay  getting  their

child immunized.  Studies  have  shown that  such missed  opportunities  contribute  to

why children  are  not  adequately  immunized.

The  VFC  program  began  October  1, 1994, and  is administered  by the  Centers  for

Disease  Control  and  Prevention  (CDC).

P@sician  Pwtici@ation 
The  national  goal is to increase  immunization  levels of 2-year-olds  for specific  antigens 
to 90 percent  by 1996.  Widespread  participation  of physicians  in the  VFC  program  is 
considered  essential  to achieve  that  goal.  However,  early  in the  program,  medical 
societies  indicated  that  many  physicians  might  not  be willing to participate  in the  VFC 
program. 
The  CDC  asked  for assistance  from  the  Office  of Inspector  General  to identi&  and 
describe  barriers  to physician  participation  in the  VFC  program.  We  conducted  this 
study in response  to that  request. 
2Federally  Qualified  Health  Centers  and Rural  Health  Clinics serve medically  underserved 
areas  and rural  areas  that  meet  qualifications  for receiving  grants  under  the Public  Health  Service 
(PHS)  Act.  FQHCS  include  community,  migrant,  or homeless  health  centers  receiving  grants  under  the 
PHS  Act. 
2  Uiziwssdtales 
Prior  tothe  VFC  program,  12 States3were  providing  free  vaccine  to private 
physicians  toimmunize  allchildren  in their  States.  These  States  are  commonly 
referred  to as universal  States.  Many  universal  States  began  their  universal  vaccine 
programs  during  the  1960s when  Federal  funding  for State-based  immunization 
programs  began. 
The  Federal  government  provides  grants  to all States  to purchase  vaccines  at the 
Federal  discount  price  and  funds  immunization  program  initiatives.  These  grants  are 
authorized  under  Section  317 of the  PHS  Act.  With  the  inception  of the  VFC 
program,  universal  States  have  additional  Federal  funds  to purchase  vaccine  for their 
Medicaid,  uninsured,  Alaskan  Native  American,  and  Native  American  children. 
Universal  States  rely heavily  on private  physicians  to immunize  children  because  they 
have  very limited  public  health  clinics.  Most  physicians  participate  in their  universal 
State  programs.  The  following  chart  illustrates  the  percentage  of physicians  who 
participated  in universal  State  programs  in 1992. 
PHYSICIAN  PARTICIPATION  IN UNIVERSAL 
STATE  VACCINE  PROGRAMS 
PERCENT 
100 
ao 
80 
70 
@o 
60 
40 
So

20

10

0

M  NC  AK  WY  GTMERI  SD  VT  MA  NH

STATE 
Note  Ratea are estimates  provided  by immunization  program  officials.  Idaho is 
not shown  beeause  participation  ratea were  not available. 
Washington  became  universal  in  1990, and  North  Carolina  in 1992.  This  may explain, 
in part,  why they  do not  have  as high physician  participation  rate  as the  other 
3Alaska,  Connecticut,  Idaho,  Maine,  Massachusetts,  New Hampshire,  North  Carolina,  Rhode 
Island,  South  Dakota,  Vermont,  Washington,  and Wyoming. 
3  universal  States.  North  Carolina  did, however,  achieve  a 70 percent  participation  rate 
within  six months  after  the  program  began.  North  Carolinas  success  is primarily  due 
to strong  support  from  medical  societies  which  lobbied  the  State  legislature  to fund 
the  program. 
As of March  1995, three  other  States  (New Mexico,  Nevada,  and  North  Dakota)  have 
become  universal. 
Non-Uiniwmil  Stwes 
Most  non-universal  States  have  public  health  departments  and  clinics.  In many  non-
universal  States,  it is common  for physicians  to refer  children  to public  health 
departments  for immunizations.  For  example,  a recent  study in New York  showed  50 
percent  of the  physicians  surveyed  referred  all or some  of their  patients  elsewhere  for 
vaccinations.4  According  to the  study, the  primary  reason  for such referrals  was the 
lack  of insurance  to cover  the  cost of immunizations. 
Some  non-universal  States  have  experience  with distributing  free  vaccines  to private 
physicians  because  they were  purchasing  vaccine  at the  Federal  contract  price  to 
distribute  to Medicaid  physicians,  commonly  referred  to as a Medicaid  Replacement 
Program.  State  health  departments  purchased  and  distributed  free  vaccines  to 
Medicaid  physicians,  and  Medicaid  reimbursed  the  State  health  department.  Non-
universal  States  also distributed  free  vaccines  to public  health  clinics for childhood 
immunizations. 
METHODS 
To identify  issues  affecting  physician  participation  in the  VFC  program,  we first 
surveyed  physicians  practicing  in universal  States.  We believed  we could  learn  from 
physician  experiences  in those  universal  State  programs.  We  asked  what  problems 
they  had  previously  encountered  and which features  of the  VFC  program  would 
influence  their  decision  to participate.  We then  considered  how the  issues  identified 
by physicians  in universal  States  might  affect  the  willingness  of physicians  in non-
universal  States  to participate  in the  VFC  program.  (We  did not  survey physicians  in 
non-universal  States  because,  at the  time  of our  survey, many  of these  States 
postponed  notifying  physicians  about  the  VFC  program  due  to delays  in establishing  a 
Federal  vaccine  delivery  system.) 
We  selected  five universal  States  in which  to conduct  the  physician  survey-
Washington,  South  Dakota,  North  Carolina,  Massachusetts,  and  Connecticut.  These 
States  were  chosen  primarily  because  they  represent  different  regions  of the  country. 
Appendix  A further  describes  our  criteria  for selecting  these  States. 
4Nlorbidity  and Mortality  Weekly Report,  Physician Vaccination  Referral  Practices,  Vol. 44, 
No.  1, January  13, 1995. 
4  In each  of the  States,  we obtained  a list of physicians  from  the  American  Board  of 
Mediml  Specialties'  official  directo~of  certified  specialists.  From  the  list of 
pediatricians,  family,  and  general  practice  physicians  we randomly  selected  150 
physicians  from  each  State,  fora  sample  of 750 physicians.  We  dropped  81 physicians 
from  the  sample  because  30 did not  give immunizations  and  51 questionnaires  were 
not  deliverable.  This  reduced  the  sample  from  750 t0669  physicians. 
Ourresponse  rate  was39  percent  (2600f669).  We  are  unable  to perform  anon-
respondents  analysis  due  to alackof  demographic  data  inour  sampling  frame.  Thirty 
of the  physicians  we surveyed  returned  questionnaires  indicating  they  did not  give 
immunizations  because  they were  retired,  subspecialists,  in academic  medicine,  or did 
not  treat  patients  two years  of age  or younger.  We believe  a large  number  of 
physicians  may not  have  responded  for these  same  reasons.  It is quite  likely that,  for 
physicians  immunizing  young  children,  we may have  a much  higher  response  rate.  In 
any event,  we believe  our  results  are  informative  and  generally  representative  of 
physicians  providing  immunization  services. 
To  put  physician  responses  in context  with  their  State  policies,  we surveyed 
immunization  program  officials  in 11 of the  12 universal  States.  One  of the  12 
universal  States  chose  not  to participate  in our  survey.  We  conducted  site visits in 
seven  universal  States  and  mailed  standardized  questionnaires  to the  remaining  five 
States. 
We  then  interviewed  immunization  program  officials from  21 non-universal  States  to 
obtain  information  on how they were  implementing  the  VFC  program  and  their 
perception  of issues  affecting  physician  participation  in non-universal  States.  We 
interviewed  the  non-universal  State  officials  at regional  meetings  sponsored  by CDC. 
The  21 States  include  the  District  of Columbia.  For  the  purpose  of this study, we will 
refer  to the  District  of Columbia  as a State. 
To  obtain  an understanding  of the  VFC  program,  we interviewed  officials  from  the 
National  Immunization  Program  and  the  National  Vaccine  Program  Office.  We  also 
interviewed  representatives  from  the  American  Academy  of Pediatrics,  American 
Medical  Association,  and  the  American  Academy  of Family  Physicians.  We  reviewed 
laws and  implementation  guidelines  for the  program,  and  reports  regarding  State 
vaccine  programs  and  related  subjects. 
We  collected  data  between  August  and  September  1994, the  two months  immediately 
before  the  program  start-up  date. 
This  report  describes  (1) the  effect  of VFC  program  requirements  on physician 
participation  in universal  States,  and  (2) the  potential  effect  of these  issues  on 
physician  participation  in non-universal  States. 
We  conducted  this inspection  in accordance  with the  Quality Standards for Inspections 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
5  reports.  However,  States  can  elect  to continue  requiring  them,  Appendix  C shows an 
example  of a vaccine  usage  report. 
The  physicians  we surveyed  said that  it is time-consuming  and  cumbersome  to break 
down  doses  administered  by age  groups  as the  vaccine  usage  reports  require. 
Physicians  said they  did not  take  the  vaccine  usage  reports  seriously  and  often  guessed 
at the  reported  information.  Officials  in some  universal  States  reported  that  some 
physicians  did not  comply  with this requirement. 
Physicians  informed  us that  the  Provider  Profile  Form  provides  unreliable  information. 
Physicians  said  they  do not  have  a credible  basis for estimating,  by eligibility  category, 
the  number  of children  they  expect  to immunize.  Thus,  the  estimates  on the  provider 
profile  do not  provide  an accurate  basis  for States  to apportion  costs of vaccines 
between  317, VFC  and  State  funds.  Some  State  officials  said they  can  estimate  the 
number  of children  to be  immunized  better  than  physicians.  For  example,  States  can 
look  at State  Medicaid  records  to determine  the  number  of Medicaid  children  eligible 
for program  vaccines. 
The  Patient  Eligibility  Screening  Record  was cited  as unreliable  for two reasons.  First, 
the  law does  not  require  that  a childs eligibility be verified.  Therefore,  parents  could 
misrepresent  their  childs eligibility  status.  Second,  physicians  are  only required  to 
complete  the  Patient  Eligibility  Screening  Record  at the  time  of the  first immunization. 
However,  a childs VFC  eligibility status  may change  after  the  first immunization.  For 
example,  it is not  uncommon  for families  to frequently  go on and  off Medicaid  during 
the  course  of a childs immunization  schedule.  In addition,  physicians  said the  Patient 
Eligibility  Screening  Record  is superfluous  in universal  States  because  they  provide 
free  vaccines  to all children  and  do not  have  to differentiate  between  which  children 
are  eligible  for VFC  program  vaccines. 
The  Physician  Enrollment  Form  should  not be  a problem  for physicians  who 
previously  completed  a similar  enrollment  form  in their  State  universal  program. 
Non-Uhivtmal  States 
We  expect  that  physicians  in non-universal  States  will have  similar  concerns  about 
paperwork  as those  cited  by physicians  in universal  States.  As noted  earlier,  fifty-two 
percent  of the  physicians  in universal  States  said the  paperwork  in their  State  universal 
program  was excessive  (even  though  they were  only required  to complete  one  form  for 
their  State  program). 
Physicians  in universal  States  said they  cannot  provide  reliable  estimates  for the 
provider  profile.  Physicians  in non-universal  States  may also be  unable  to provide 
reliable  estimates. 
Although  physicians  in universal  States  said the  Patient  Eligibility  Screening  Record 
was superfluous  in universal  States,  this record  could  serve  a purpose  in non-universal 
7  States.  It could  act  as a deterrent  for abuse,  and  provide  physicians  a means  to 
determine  if a child is eligible  for VFC  program  vaccines. 
To  further  illustrate  the  problem  of excessive  paperwork,  we note  that  paperwork  was 
one  reason  why States  did not  have  success  in getting  physician  participation  in their 
Medicaid  vaccine  replacement  programs.  For  example,  when  North  Carolina  was a 
non-universal  State  they  conducted  a study to determine  the  extent  of participation  in 
their  Medicaid  replacement  program.  The  study showed  that  79 percent  of the 
physicians  said they  did not  participate  in the  replacement  program  because  of 
excessive  paperwork.5 
INEFFICIENT  VACCINE  DELIVERY  SYSTEMS COULD DISCOURAGE 
PHYSICIAN  PARTICIPATION 
Delivery  systems  generally  fall into  two categories.  Vaccines  may be  delivered  to a 
State  depot  and  then  shipped  directly  to physicians,  or vaccines  maybe  delivered  to a 
State  depot  and  then  shipped  to drop  points within  a State,  such  as local  health 
departments,  clinics, and  local  hospitals.  In drop-point  systems,  physicians  must 
arrange  to pick up vaccines  from  the  drop  points. 
WlivmaSltutei$ 
Eight  of the  universal  States  we surveyed  have  direct  delivery  systems,  three  have

drop-point  systems.  In the  States  where  we surveyed  physicians,  South  Dakota,  North

Carolina,  and  Massachusetts  have  direct  delivery  systems; while  Washington  and

Connecticut  have  drop-point  systems.  Thirty-eight  percent  (38 of 101) of the

respondents  from  States  with  drop  points  and  31 percent  (49 of 159) of the

respondents  from  direct  delivery  systems  complained  about  the  efficiency  of their  State

delivery  systems!

Physicians  identified  problems  applicable  to both  direct  delivery  and  drop-point

systems  including  vaccines  not  being  delivered  on time  and  in the  correct  quantities

ordered.  Physicians  said when  such problems  occur,  they must  turn  patients  away and

an opportunity  to immunize  is missed.

Physicians  in States  with  drop-point  systems  cited  additional  problems  including

pick-up  times  at drop  points  are  frequently  inconvenient, 
 
physicians  or their  employees  must  drive  long distances  to drop  points, 
 
Garrett, J., The Impact  and Implications  of Referrals  to Health  Departments  for 
Immunizations:  University  of North  Carolina,  September,  1992. 
%here  is no statistically  significant  difference  behveen  the number  of complaints  in drop-point 
systems and the number  of complaints  in direct  delive~  systems. 
8  drop  point  employees  are  busy, andphysicians  ortheir  employees  have 
	
experienced  long waits  to obtain  vaccines,  and 
after  driving  long distances,  and waiting  for service,  physicians  are  sometimes 
	
told  that  vaccines  are  not  available. 
State  ofilcials  in States  with direct  delive~  systems  contend  direct  delivery  is better 
because  it facilitates  communication  between  State  agencies  and  physicians.  For 
example,  they  put  letters,  pamphlets,  and  new immunization  schedules  in with vaccine 
shipments. 
Non-Uirivemd  i?htes 
The  delivery  of vaccines  to physicians  in non-universal  States  may present  a particular 
problem  for the  VFC  program.  If physicians  perceive  inordinate  vaccine  delive~ 
problems,  they  may be  less likely to participate,  especially  if children  who  are  eligible 
for the  VFC  program  represent  a small  portion  of the  physicians  practice.  Likewise, 
if physicians  experience  vaccine  delivery  problems  while  participating,  they may  drop 
out  of the  program.  Inefficient  vaccine  delivery  systems  not  only lose the  opportunity 
to immunize  but  can  also  hinder  the  relationship  between  the  physician  and  patient. 
LACK  OF VACCINE  DELIVER Y SYSTEMS IN SOME STATES IMPEDES 
PHYSICIAN  PARTICIPATION 
According  to VFC  legislation,  Federal  funds  are  to finance  delivery  of program 
vaccines.  Only one  vaccine  manufacturer  would  agree  to a delivery  contract  at the 
capped  vaccine  price,  so no Federal  delivery  system  has been  established.  However, 
CDC  continues  to explore  other  delivery  options. 
All States  are  delivering  vaccine  to the  public  sector  which  accounts  for about  50 
percent  of the  nations  immunizations.  For  private  provider  delivery,  as of March  30, 
1995, 35 States  (including  all  12 universal  States)  have  established  vaccine  delivery 
systems  using  available  Federal  funding.  Alaska  also has  a distribution  system; 
however,  they  operate  a centralized  distribution  system  separate  from  the  VFC 
program.  At least  10 of the  remaining  14 States  reported  they  plan  to begin  delivering 
vaccine  this year.  This  lack of private  sector  delivery  has  impeded  private  physician 
participation  in these  14 States. 
NEWLY  ESTABLISHED  MAXIMUM  ALLOWABLE  VACCINE 
ADMINISTRATION  FEES FOR PHYSICIANS  COULD HELP OVERCOME  A 
BARRIER  TO PHYSICIAN  PARTICIPATION 
Prior  to the  VFC  program,  physicians  could  charge  parents  a fee  for  administering 
free  vaccines  in universal  States.  Most  universal  States  allowed  physicians  to charge 
parents  from  two to ten  dollars  per  dose.  Some  universal  States  did not  specify  an 
amount,  but  told  physicians  they  could  charge  parents  a reasonable  amount.  The 
9  allowable  fees,  however,  discouraged  some  physicians  from  participating  in State-
sponsored  programs.  To  illustrate,  25 percent  (64 of 260) of the  universal  State 
physicians  we surveyed  said the  fee their  State  allowed  was inadequate.  Twelve 
percent  (31 of 260) of the  physicians  we surveyed  said the  amount  physicians  were 
allowed  to charge  parents  was important  to getting  physician  participation  in the  VFC 
program. 
Under  the  VFC  program,  the  Health  Care  Financing  Administration  (HCFA) 
established  maximum  allowable  vaccine  administration  fees  that  physicians  in each 
State  could  charge  parents.  The  maximum  allowable  fees  represent  a cap,  not  a 
required  amount.  However,  if universal  States  adopt  HCFAS maximum  allowable 
fees,  physicians  in universal  States  will be  allowed  to charge  parents  significantly  more 
than  they were  allowed  to charge  previously  under  their  State  program.  The 
maximum  allowable  fees  are  comparable  to what  physicians  charge  parents  to 
administer  privately-purchased  vaccines.  Therefore,  the  newly established  rates  should 
encourage  physician  participation  in the  VFC  program. 
HCFA  based  the  maximum  allowable  rates  partly  on studies  done  by the  American 
Academy  of Pediatrics  (AAP).  Under  a HCFA  contract,  AAP  conducted  a survey of 
physicians  to obtain  national  data  on administration  fees  for pediatric  immunizations. 
The  survey showed  that  the  average  administration  fee  to private  pay patients  for each 
dose  of pediatric  vaccine  is $15.09.  The  HCFA  then  adjusted  the  average  rate  for 
geographic  cost differences  to establish  a maximum  allowable  physician  fee  for 
administering  VFC  vaccines.  The  maximum  rates  were  set based  on charge  data 
rather  than  cost data  which was required  by law.  HCFA  plans  to revise  the  maximum 
rates  based  on cost  data.  Appendix  D shows, by State,  the  maximum  fees  established 
by HCFA. 
State  Medicaid  agencies  are  not  obligated  to set their  Medicaid  VFC  administration 
fees  at the  maximum  level  established  by HCFA.  However,  13 of the  21 non-universal 
States  we surveyed  said they would  do so, or they would  establish  a slightly lower  fee. 
To  encourage  physician  participation  in the  VFC  program,  several  non-universal  States 
are  offering  additional  incentives.  For  example,  one  State  has offered  an additional  $5 
to physicians  for every new child they  get to complete  the  immunization  series. 
Another  State  plans  to pay physicians  $3 for each  dose  administered,  to offset 
paperwork  requirements. 
10
 RECOMMENDATIONS

Physician  participation  in the  VFC  program  is essential  to reach  the  National  goal  to 
increase  immunization  levels of 2-year-olds  for specific  antigens  to 90 percent  by 1996. 
Our  study showed  that  unreliable,  burdensome  accountability  requirements  and 
inefficient  vaccine  delivery  systems  could  adversely  affect  a physicians  decision  to 
participate  in the  program.  Therefore,  we make  two recommendations  that  we believe 
will further  the  goals  of the  VFC  program. 
continuteo
 develbp  @iciknt  and reliizble vaccine accountizbility rnedumiwns. 
The  CDC  should  explore  alternative  means  to obtain  the  information  intended  to be 
provided  by the  provider  profile.  For  example,  States  could  use Medicaid  records  to 
determine  how many  Medicaid  children  are  eligible  for VFC  program  vaccines.  Other 
records  may be  readily  available  to determine  how many  uninsured,  underinsured, 
Native  Alaskan  American,  and  Native  American  children  are  eligible.  States  could 
conduct  random  sample  surveys of physicians  to confirm  these  projections.  The  CDC 
is already  reexamining  how to validate  the  provider  profile  information  through 
implementing  a usage  based  system.  CDC  is conducting  a study to evaluate  methods 
of accountability  for VFC  vaccines  based  on actual  vaccine  usage  data.  We  encourage 
CDC  to continue  these  efforts. 
In addition,  CDC  should  examine  the  efficacy of the  Patient  Eligibility  Screening 
Record  in universal  States.  These  States  may already  have  effective  systems  in place 
to accomplish  what  was intended  by the  Patient  Eligibility  Screening  Record.  The 
CDC  has told  us they  are  aware  of this issue and  are  examining  the  legal  and  policy 
implications. 
Contbu4e to explore altematiw  vaccine deliwy  systems. 
Obviously,  the  lack  of vaccine  delivery  systems  to private  providers  in fourteen  States 
impedes  physician  participation  in the  VFC  program  as well as the  ability  of the 
program  to increase  childhood  immunizations  in those  States.  The  CDC  informed  us 
that  they  are  working  with  interested  parties  to establish  vaccine  delivery  systems. 
In addition,  CDC  should  examine  the  efficiency  of drop-point  systems  and  direct 
delivery  systems.  Physicians  we surveyed  described  problems  with both  types  of 
delivery  systems.  If physicians  experience  vaccine  delivery  problems  while 
participating,  they  may drop  out  of the  program. 
11
 AGENCY  COMMENTS

The  Assistant  Secretary  for Health  commented  on our  draft  report  and  concurred  with 
our  recommendations.  He  expressed  CDCS concerns  that  the  accountability  system 
for the  VFC  program  balance  the  need  for  accountability  with the  need  for a system 
that  encourages  physician  participation  and  reported  that  CDC  is continuing  to 
develop  accountability  systems.  Further,  he stated  that  CDC  is committed  to 
establishing  a delivery  system  for States  who do not  choose  to deliver  vaccines 
themselves. 
The  Assistant  Secretary  for Health,  the  Health  Care  Financing  Administrator,  and  the 
Assistant  Secretaxy  for Planning  and  Evaluation  provided  additional  points  of 
clarification  and  technical  comments  which we responded  to by editing  portions  of the 
report.  Appendix  E shows the  full text  of the  comments. 
12
 APPENDIX  A

SAMPLE OF FIVE UNIVERSAL  STATES 
FOR PHYSICIAN  SURVEY 
(Source  STATE  YELLOWBOO~  VOL. ~ No. 1, Spring  1993) 
NOTES: 
1.  The  sample  reflects  geographic  and  demographic  diversity. 
2.	 Two New England  States  were  selected  because  half  of the  12 universal  States 
are  in that  region. 
A-1
 APPENDIX  B 
PHYSICIAN  ENROLLMENT  FORM 
PROVIDER  PROFILE FORM 
PATIENT  ELIGIBILITY  SCREENING RECORD 
B-1  Provider Enrollment 
Vaccines for Children Program  = 
Physician or Cfinic 
Address 
() 
()
Telephone 
Fax 
Contact Name(s) 
Employer Identification Number 
IS your practicdctinic  a Federtily  Qualified He~tb Center (FQHC) or R~  He~ti 
CliniC  (RHC)?  YN 
In order to participate in the Vaccines for Children (VFC) program and/or to receive other federally procured vaNcocine provided 
 
tome  at no COSLI, on behalf of myself and any and all practitioners associated with this medical office, group practice, Health 
Maintenance Organization,  health departmen~ community/mi~atimrd  clinic, or other entity of which (you are the physi
cian-in-chief or equivalent) agree to the following: 
1.	 WC  program-purchmed  vaccine will be administered only to a child (48  years of age) who: (a) is on Medicaid (or 
qualifies through a States Medicaid waiver), or (b) has no health inswance,  or (c) is an American Indian or Alaskan 
Native, or (d) has health insurance that does not pay for the vaccine (applicable only to vaccines administered by or on 
behalf of a FQHC or RHC). 
2.	 Iwillmaintainrecordsoftheauthorizedrepresentativesresponsesforaperiodof 3years, unless State requirements call 
for a longer duration. Release of such records will be bound by the privacy protection of Federal Medicaid law. 
3.  If requested, I will make such records available to the State or the Department of Health and HumaTIServices (DHHS). 
4.	 I will comply with the appropriate immunization  schedule, dosage, rmd contraindications,  that is established by the DHHS 
Advisory Committee on Immunization  Practices, unless (a) in making a medid  judgment in accordance with accepted 
medical practice, I deem such complianm  to be medically inappropriate or (b) the particular requirement  is not in compli
ance with the law of my State, including State laws relating to religious or other exempt.ions.# 
5.	 I will provide vaccine information materials and maintin  records in accor~ce  with the National Childhood Vaccine 
Injury Act.* 
6.  I will not impose a charge for the cost of the vaccine.* 
7.	 I will not impose a charge for the adminismation of the vaccine in any amount higher than the maximum fee established by 
DHHs. 
8.	 I will not deny administration  of a federally procured vaccine to a child due to the inability of the childs parent/gutiditi 
individud  of record to pay an adminiswative fee. * 
9.  I will comply with the States requirements  for ordering vaccine and other requirements  as outlind  on the attached 
10.	 form(s).* 
I or the State may terminate this agreement at any time for personal reasons or failure to comply with these 
requirements.* 
provider Signature 
Date 
This record is to be subrnittd  to and kept on file at the State Health Department or State Public Health Agency and must be 
updated in accordance with State policy. 
*If a provld~r~elves v~~ne purchmti  f~erd  contracts, but is not enrolled in the WC  program, then the provider is 
off 
only required to agree to these conditions. 
# Note: The ACIP Immunization  Schedule is compatible with the AAP recommen&tions. 
For State use onty (enter date in onty one box): 
Date certified fm VFC: 
Me  certifkd for vaccine purchased off Federal conrract.s,excluding  VFC: 
II 
1 
Date MM  for VW and othez vaccine purchased off Fedd  contracts:  Provider  Profile 
@K!?%_l 
Vaccines for Children Program 
Date: 
All public and private healthcare providers approved by the State for participation in the Vaccines for Children Program (WC) 
must complete this form. This document provides shipping information and helps the State determine the amount of vaccine to 
be supplied through the VFC program. The form also maybe  used to compare estimated vaccine needs with actual vaccine 
supply. The State or Immunization  Project must keep this record on fde with the Provider Enrollment form. The Provider 
Profile form must be updated annually or more frequently if  (1) estimates of children served changes, or (2) the status of the 
facility changes (e.g., private provider becomes an agent of a Federally Qualified Health Center). This form may be completed by 
one provider for the entire practice. 
A. Employer Identiilcation  Number: 
B. Facility Name: 
or 
Provider Name: 
Lmt Name  First Name  MI 
C. Contact Name(s): 
LastName  First Name  Ml 
D. Vaccine Delivery Address (no PO Boxes): 
City  State  Zipcode 
()  ()

Telephone  Fax 
E. Type of Facility (please  check only one box): 
c1  10  Public  Health Department 
o  11  Public Hospital 
o  12  Other Public 
Q  13  Federally Qwdified Health Center or Rural Health Clinic 
(check here ifan  agent of a FQHC or RHCfor  the VFC program)  Cl 
0  20  Private  Practice (Individual or Group) 
Cl  21  Private Hospital 
c1  22  Other Private 
<1 y=  old  1 through 18 years  Total 
F. For the 12-month period beginning  10/1/94, 
estimate the numbers of children who will receive 
vaccinations at your practice/clinic. 
G. Of the total numbers entered above, how many 
Note: Do not count a child in more than  one category. 
children are expected to be VFC eligible because they ara 
Emolled  in Medicaid 
Without health insurance 
American Indian or Ataskan Native 
Underinsured* 
Total 
* Complete  only if E -13 above  & checked  (either box). 
  I 
Patient Eligibility  Screening Record 
Vaccines for Children Program  = 
Date 
Child 
kt  Name 
First Name 
MI 
Date of Birth 
Parent/Guardian/ 
Individual of Record 
Last Name 
First Name 
Ml 
Provider 
A record must be kept in the healthcme providers office that reflects the status of all children 18 years of 
age or younger, who receive immunization through the VFC program. The record may be completed by 
the parent, guardian or individual of record, or by the healt.hca.reprovider. This same record may be used 
for all subsequent visits as long as the childs eligibility status has not changed. While verification of 
responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine. 
II@ child  qualifies  for vaccination  through  the VFC program  because  hekhe  (check  only one box): 
(a)  is enrolled in Medicaid   
or
(b)  does not have health insurance 
c1  or 
(c)  is American Indian or Alaskan Native  c1 
or 
(d)  has health  insurance that Does Not pay for vaccines

c1  or

(Applicable only to children attending a Federally Qualified Health Center 
or Rural Health Clinic.)
 APPENDIX  C 
VACCINE  USAGE REPORT 
c-1  QUARTERLY VACCINE USAGE REPORT 
AGE-SPECIFIC  DOSES ADMINISTERED 
Name  of  Health  Care  Provider  I 
Quarter:  [ ] 1 (Jan-Mar) 
Addres=  [ 12  (Apr-June) 
[ 13  (July-Sept) 
Year:  [ 14  (Ott-Dee) 
Telephone  -
Person  Completing  Report 
Enter  on  the  appropriate  line  designated  for  each  vaccine,  the  total number  of  doses  given  of  each  vaccine  according  to  age 
groups  indicated.  Please  DO NOT  use  hash  marks.  Use  additional  copies  for worksheets. 
Type  TOTAL  DOSES  GIVEN,  BY  PATlENT  AGE-GROUP 
of 
<1  1  2  3-4  5  6-9  10-14  15-19  20-24  25-44  45-64  65  +  Total
Vaccine 
DTP 
DT  (peals) 
Td  (adult)  ;  :  ,:, ~~~  : ,:.  :  . .,:;  ;.:.::,,;  ,! ,,  : 
HibTITER 
PedvaxHIB 
OOPOVO

I.P,V,

M/M/R 
I 
Influenza  .= 
Hep  B (infant) 
This  report  is authorized  by law  (42 USC  247b.  42CPR  51 b.) and is to be submitted  by the  5th  working  day  of each  quarter. 
Its  submission  is needed  to  provide  effective  program  management  and is a condition  of immunization  project  grant  awards. 
)istnbution  White -tmmunizatmn  Program  Yellow-Provider  06-E PI-IZ.1 10 IWqrn  PUBLIC  HEALTH  SERVICE  (PHS)  C()~ENTS  ON  THE  OFFICE  OF 
INSPECTOR  GENERAL  (OIG)  DRAFT  REPORT  PHYSICIAN  PARTICIPATION 
IN  THE  VACCINES  FOR  CHILDREN  PROGRAM,    0EI-04-93-O0320 
OIG  Recommendation 
We  recommend  that  the  Centers  for  Disease  Control  and 
Prevention  (CDC): 
1.	 Continue  to  develop  efficient  and  reliable  vaccine 
accountability  mechanisms. 
PHS  Response 
We  concur.  Financial  accountability  is  an  essential  part  of 
the  Vaccines  For  Children  (VFC)  program.  The  States  have 
primary  responsibility  for  accounting  for  vaccine.  Given

their  30  plus  years  of  experience  managing  immunization

programs,  the  States  are  in  the  best  position  to  account  for

vaccines  because  of  their  knowledge  of  unique  circumstances

and  provider  practices. 
The  OIG  report  documents  concerns  that  additional  paperwork 
requirements  will  discourage  physicians  from  participating  in 
the  VFC  program.  Because  of  this  concern,  CDC has  developed 
an  accountability  system  for  the  VFC  program  that  balances  the 
essential  need  for  accountability  with  the  mandate  to 
encourage  physicians  to  participate  i.n  the  program.  If  CDC 
had  required  providers  to  report  each  immunization 
transaction,  they  would  be  burdened  with  filling  out  and 
sending  in  over  14  million  pieces  of  paper  a  year. 
The  CDC  is  continuing  to  develop  additional  accountability 
mechanisms  .  CDC  officials  have  met  with  States  to  review 
State  accountability  plans  and  to  identify  promising 
approaching  to  accountability.  The  CDC  is  also  working  with 
Battelle  to  pilot  test  additional  accountability  methods  in 
.
selected  States. 
Recommendation 
2.  Continue  to  explore  alternative  vaccine  delivery  systems. 
PHS  Response 
We  concur.  The  CDC  is  committed  to  establishing  a  delivery 
system  for  those  States  which  do  not  choose  to  deliver 
vaccines  themselves.  Initially,  as  requested  bv  the  States, 
CDC  proposed  distributing  vacc~ne  to  p~ivate  ph~sicians  in  -
selected  States  through  a  national  distribution  center. 
However,  the  Congress  preferred  having  the  private  sector 
carry  out  this  vaccine  distribution.  Accordinglyf  in 
September  1994,  CDC began  negotiations  with  vaccine 
  2

manufacturers  with  anticipation  of  delivery  to  private

physicians  in December.  On April 10, CDC  had  to  discontinue

these  negotiations.  Although  final  agreement  was  reached  with

one  manufacturer,  it  was  determined  that  time  was  not

available  to  reach  agreements  with  the  remaining

manufacturers.  CDC is  now  holding  meetings  with  interested

parties  to  determine  the  most  appropriate  manner  to  conduct

this  vaccine  delivery.

Despite this, it should be recognized that VFC vaccine  is

being delivered  to tens of thousands of public and private

providers.  All States are delivering vaccines to public 
clinics, which account for about 50 percent of immunizations 
nationwide.  In addition, as of March 30,  35  States  had 
informed  CDC that  they  were  delivering  vaccine  to  enrolled 
private  providers.  All  of  the  remaining  14  States  reported 
they  plan  to  begin  delivering  vaccine  to  private  providers 
this  year  or  next  year.  [Alaskar  which  already  delivers 
vaccines  to  all  providers  in  the  State,  is  not  participating 
in  the  VFC  program.  ]  %*Me	
TtIe Admmwataf 
Washingran.  D,C,  20201 
DATE  MY22 ~ 
To  JuneG ibbBsrown 
~ 
~  ~~  &w 
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.  DEPARTMENT  OF HEALTH&  HUMAN  SERVICES  Office  of  the  Secretary
.: 
:
7,
.0 
+7,,,1,,  Washington,  D.C.  20201 
JUN  9  !995 
TO:	 June Gibbs Brown 
Inspector  General 
FROM:  Assistant  Secretary 
for Planning  and Evaluation 
. 
SUBJECT:	 OIG Draft Report:  Physician Participation  in the Vaccines  for Children 
Program,  OEI-04-93-O0320 
Thank you for providing  me with a draft of the above mentioned  report for review  and 
comment.  I understand  that the Public Health Service and the Health Care Financing 
Administration  are also reviewing  the report and will be providing  your office with  specific 
comments.  We would defer to their expertise  and experience  with the VFC program  in 
addressing  any concerns  they might have with the report.  In addition,  we would suggest that 
a clarification  be made within the Executive  Summary and the body of the report  emphasizing 
that the data was collected  prior to the implementation  of the VFC program  on October  1, 
1994.  While  some states may have informed their physicians  about the anticipated 
requirements  of the VFC program  prior to October  1, 1994 other states may not have done so 
by the time data was collected. 
.

DavidT.Ellwood

Preparebdy
 Amy Nevel,OASPE