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Health Objectives for the Nation Race-Specific Differences in Influenza Vaccination Levels Among Medicare Beneficiaries -- United States, 1993

One national health objective for the year 2000 is to provide annual influenza vaccination to 60% of all noninstitutionalized, high-risk populations in the United States, (objective 20.11) (1). Since May 1, 1993, Medicare has reimbursed providers for the cost of influenza vaccine; reimbursement for the administration of the vaccine also has been provided for beneficiaries with part B coverage, which allows them to receive the vaccine without a copayment and without having to meet the annual deductible amount for part B reimbursement. Approximately 96% of all persons aged greater than or equal to 65 years in the United States have Medicare part B coverage (Health Care Financing Administration {HCFA}, unpublished data, 1994). To characterize patterns of vaccine use by Medicare beneficiaries, HCFA and CDC estimated influenza vaccine use by Medicare beneficiaries during September- December 1993. Because of disparities in vaccine use by race, this analysis focused on race-specific differences between blacks and whites. This report presents the findings of that analysis.

Claims submitted for services provided during September 1- December 31, 1993, and paid by Medicare were used to identify persons who received influenza vaccine. The percentage of beneficiaries who received Medicare-paid vaccinations was calculated using the HCFA 1993 denominator file for beneficiaries aged greater than or equal to 65 years for the United States and for each state and county, by sex, 10-year age group, and race (white and black {data for racial groups other than whites and blacks are grouped together in the Medicare claims data system and were not analyzed separately}) (Table_1 and Table_2). Medicare claims are not submitted by managed-care plans; therefore, beneficiaries who are members of such plans (approximately 6% of the Medicare population) were excluded from the analysis. Because 1993 was the first year influenza vaccination was reimbursed by Medicare, approximately 10%-20% of Medicare beneficiaries may have been vaccinated in 1993 and not had claims filed with Medicare (CDC, unpublished data, 1994).

During 1993, a total of 9,831,884 (35%) beneficiaries received Medicare-reimbursed influenza vaccinations. However, the vaccination rate for blacks (17%) was less than half that for whites (37%) Table_1. Among whites, the vaccination rate for women aged greater than or equal to 85 years (30%) was lower than that for women aged 65-84 years by approximately eight percentage points and lower than that for men aged greater than or equal to 85 years by approximately five percentage points (p less than 0.01 for both comparisons). Among blacks, vaccination rates varied 1%-3% between different age-sex groups Table_1.

Coverage rates for Medicare-reimbursed influenza vaccination ranged from 16% (Alaska) to 49% (Iowa) Table_2. Vaccination levels were greater than or equal to 40% in 20 (40%) of the 50 states and in the District of Columbia. In 33 (66%) states and in the District of Columbia, vaccination rates for blacks were below 60% of the rates for whites. Vaccination rates for blacks were at least 60% of the rates for whites in 17 states *; in these states, the total black population aged greater than or equal to 65 years with Medicare part B coverage was 65,515 (3% of the national black population that has Medicare part B coverage). Reported by: AM McBean, MD, Univ of Minnesota School of Public Health, Minneapolis. JD Babish, MPH, Office of Research and Demonstrations, Health Care Financing Administration. Adult Vaccine Preventable Disease Br, National Immunization Program, CDC.

Editorial Note

Editorial Note: The findings in this report are consistent with previous surveys that have documented lower influenza vaccination coverage among blacks than whites. For example, based on the 1991 National Health Interview Survey, among all persons aged greater than or equal to 65 years, 41% had been vaccinated; however, within this age group, blacks were less likely than whites to have been vaccinated (27% and 43%, respectively) (2). Findings from the Medicare Current Beneficiary Survey (September-December 1992) indicated that, for noninstitutionalized beneficiaries, the vaccination rate during winter 1991-92 was 48% overall but 29% among blacks and 50% among whites (Office of the Actuary, HCFA, unpublished data, 1994). These variations may reflect differences in factors such as socioeconomic status, access to medical care, and prevalence of specific risks.

The finding in this report that greater than or equal to 40% of beneficiaries in 20 states and the District of Columbia had received vaccine indicates that, in these areas, substantial progress has been made toward achieving the national health objective for the year 2000 (1,3). Because the wide variations in state-specific vaccination levels Table_2 also have been documented for Medicare-reimbursed pneumococcal vaccination claims (4), analysis of these variations may assist in planning programs for increasing vaccine coverage.

Because not all providers submitted claims to Medicare for reimbursement, the rates for Medicare-reimbursed influenza vaccination claims in this report are lower than those based on other national surveys. However, failure to submit claims to Medicare in 1993 for influenza vaccination services is not known to have differentially affected claims submitted for vaccinations administered to black beneficiaries compared with white beneficiaries. In the future, reporting may be enhanced through communication with public and private providers; the use of simplified billing procedures; and helping public-sector providers, visiting nurse groups, and others obtain Medicare provider numbers (5).

HCFA is collaborating with a coalition representing approximately 160 community organizations to identify strategies to improve coverage in 1995. In addition, as part of HCFA's Consumer Information Strategy (6), demographic- and county-specific vaccination rates for 1993 (7) were provided to health-care providers; consumer-based organizations; local, state, and other federal agencies; and Medicare beneficiaries. This information should assist in increasing beneficiary use of influenza vaccine and addresses consumer and provider concerns about the risks for influenza and the effectiveness and safety of influenza vaccine (8- 10). The county-specific vaccination rates also may assist programs receiving federal childhood vaccination grants to improve influenza vaccination coverage.


  1. Public Health Service. Healthy people 2000: national health

promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:122-3; DHHS publication no. (PHS)91-50213.

2. Heath KA, Strikas RA, Stevenson J, Williams WW. Influenza and pneumococcal vaccination among older adults: results of the 1991 National Health Interview Survey {Abstract}. In: Program and abstracts of the CDC Epidemic Intelligence Service 43rd annual conference. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994:33.

3. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.

4. McBean AM, Babish JD, Prihoda R. The utilization of pneumococcal polysaccharide vaccine among elderly Medicare beneficiaries, 1985 through 1988. Arch Intern Med 1991;151:2009-16.

5. CDC. Implementation of the Medicare influenza vaccination benefit -- United States, 1993. MMWR 1994;43:771-3.

6. Vladeck BC. From the Health Care Financing Administration: the consumer information strategy. JAMA 1994;272:196.

7. Health Care Financing Administration. 1993 Influenza immunizations paid for by Medicare: state and county rates. Baltimore: US Department of Health and Human Services, Health Care Financing Administration, 1994.

8. CDC. Adult immunization: knowledge, attitudes, and practices -- DeKalb and Fulton counties, Georgia, 1988. MMWR 1988;37:657-61.

9. Fiebach NH, Viscoli CM. Patient acceptance of influenza vaccination. Am J Med 1991;91:393-400. 10. Williams WW. Hawaii pneumococcal disease initiative: surveys of consumer and physician knowledge. In: 26th National Immunization Conference proceedings. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Prevention Services, Division of Immunization, 1992;117-22.

* Alaska, Connecticut, Hawaii, Idaho, Kentucky, Maine, Minnesota, Montana, Nevada, New Hampshire, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, Wisconsin, and Wyoming.

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TABLE 1. Number and rate of influenza vaccinations paid for by Medicare part B, by recipient
age, sex, and race -- United States, 1993

Race * /Sex/                No. non-HMO +       No. Medicare-paid       Medicare-paid
  Age group (yrs)        part B enrollees     influenza vaccinations   vaccination rate
  65-74                      5,483,480             1,883,175                34%
  75-84                      3,404,559             1,367,802                40%
   >=85                        844,735               291,706                35%
  Total                      9,732,774             3,542,683                36%

  65-74                      6,882,485             2,556,524                37%
  75-84                      5,561,678             2,136,587                38%
   >=85                      2,256,534               684,299                30%
  Total                     14,700,697             5,377,410                37%

  65-74                     12,365,965             4,439,699                36%
  75-84                      8,966,237             3,504,389                39%
   >=85                      3,101,269               976,005                31%
  Total                     24,433,471             8,920,093                37%

  65-74                        456,776                64,127                14%
  75-84                        251,261                43,612                17%
   >=85                         68,566                10,990                16%
  Total                        776,603               118,729                15%

  65-74                        655,873               118,960                18%
  75-84                        467,096                92,067                20%
   >=85                        187,636                31,590                17%
  Total                      1,310,605               242,617                19%

  65-74                      1,112,649               183,087                16%
  75-84                        718,357               135,679                19%
   >=85                        256,202                42,580                17%
  Total                      2,087,208               361,346                17%
* Data for racial groups other than whites and blacks are grouped together in the
  Medicare claims data system and were not analyzed separately.
+ Health maintenance organization.

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TABLE 2. Rates of influenza vaccination paid for by
Medicare, by state and race * of recipient -- United States, 1993
State                       White      Black   Total +
Alabama                      39         19       35
Alaska                       19         18       16
Arizona &                    44         22       42
Arkansas                     46         24       44
California &                 28         15       26
Colorado                     47         21       46
Connecticut                  35         22       35
Delaware                     32         17       30
District of Columbia         32         14       20
Florida                      41         18       40
Georgia                      38         16       33
Hawaii                       34         24       36
Idaho                        47         31       46
Illinois                     31         11       29
Indiana                      42         19       41
Iowa                         49         27       49
Kansas                       46         21       45
Kentucky                     35         21       34
Louisiana                    29         14       26
Maine                        42         31       42
Maryland                     37         17       34
Massachusetts                18          9       17
Michigan                     33         18       32
Minnesota                    43         26       43
Mississippi                  27         15       24
Missouri                     36         16       34
Montana                      48         35       48
Nebraska                     46         22       45
Nevada                       23         15       23
New Hampshire                35         28       34
New Jersey &                 27         16       26
New Mexico                   28         14       27
New York                     34         13       31
North Carolina               41         18       37
North Dakota                 41         28       41
Ohio                         36         21       35
Oklahoma                     39         18       38
Oregon                       46         25       45
Pennsylvania                 40         22       38
Rhode Island                 41         27       40
South Carolina &             36         18       32
South Dakota                 41         32       40
Tennessee                    46         21       43
Texas                        34         15       32
Utah                         34         20       34
Vermont                      34         33       33
Virginia                     45         24       41
Washington                   42         24       42
West Virginia                29         19       29
Wisconsin                    45         27       45
Wyoming                      29         24       29

Total                        37         17       35
* Data for racial groups other than whites and blacks are grouped together in the
  Medicare claims data system and were not analyzed separately.
+ Includes persons in all racial groups and persons of unknown race.
& After the mailing of the original estimates from the Medicare claims data to the 63
  federal vaccination grant programs, California and South Carolina reported 473,062 and
  23,322 influenza vaccinations administered to persons aged >=65 years, respectively,
  which were not billed to Medicare in 1993. Arizona estimated that an additional 40,000
  persons received vaccine that was not billed to Medicare, and New Jersey estimated
  80,000-100,000 doses were not billed. This additional information is not reflected in
  the table.

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