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Medicare Influenza Vaccine Demonstration -- Selected States, 1988-1992

Influenza and its complications remain a major cause of premature death and debilitating illness in the United States, particularly among older persons and those with chronic medical conditions. However, only 30% of persons greater than or equal to 65 years of age responding to the 1989 National Health Interview Survey reported having received influenza vaccine during the previous year (CDC, unpublished data, 1991). In 1988, the Health Care Financing Administration (HCFA) and CDC began a congressionally mandated 4-year demonstration project to evaluate the cost-effectiveness of providing influenza vaccine under Medicare. This report reviews preliminary results of the Medicare Influenza Vaccine Demonstration during 1988-1992.

Using intervention and control areas in Arizona, Illinois, Massachusetts, Michigan, New York, North Carolina, Ohio, Pennsylvania, and Texas and the entire state of Oklahoma * (total Medicare population: approximately 2 million), the demonstration seeks to 1) increase the provision of annual influenza vaccination among Medicare beneficiaries and 2) measure accrued benefits in terms of reduced morbidity, mortality, and health-services use. Special efforts have been undertaken in intervention areas to enhance vaccine delivery and to promote vaccine use. Levels of vaccination coverage were assessed at baseline and have been assessed annually at all sites. Analysis of the cost-effectiveness of influenza vaccination in this population has not been completed.

Vaccine Delivery and Promotion

In intervention areas, influenza vaccine is supplied without cost to providers by local health departments through computerized monitoring and distribution systems. Providers are reimbursed for administration of vaccine.

Before the 1990-91 and 1991-92 influenza seasons, HCFA sent a letter directly to Medicare beneficiaries in the intervention sites urging them to receive influenza vaccine. The letter contained specific program information and a local phone number for questions.

Project staff in intervention areas developed motivational techniques to make influenza vaccination a routine practice in provider offices and to enhance consumer demand for influenza vaccination. These techniques included providing continuing education credits to nurses who were taught how to identify high-risk patients in physician office settings, using physician prompts and chart flags to help providers identify patients for vaccination during routine office visits, and inserting vaccination messages in telephone company mailers.

In addition, project staff in Maricopa County, Arizona, used an existing 24-hour, bilingual community information and referral agency to answer patients' inquiries and refer patients to participating medical providers. From October through December 1991, more than 24,000 influenza-related calls were handled by the agency. Vaccination services in Arizona were also improved by allowing private physicians to advertise and run large-scale public clinics in shopping malls and supermarkets, one of which accounted for more than 18,000 vaccinations (1).

During 1989-90, in Rochester, New York, a sample of private physicians was able to achieve an approximately 30% increase over a control group in coverage rates (66% versus 50%) by reviewing their office records to identify patients in need of vaccine and graphing on a wall poster progress toward achieving full vaccination (2). During 1990-91 and 1991-92, this target-based system was expanded countywide and included an incentive of bonuses above the usual vaccine-administration fees for practices that vaccinated 70% or more of their target population. Preliminary data indicate that during the 1991-92 influenza season physicians participating in the system vaccinated 72% of their eligible Medicare patients.

Vaccination Coverage

Substantial improvements in vaccination coverage occurred in the intervention areas during the 4-year period. The number of doses of vaccine administered during the demonstration and the percentage of the Medicare population vaccinated in the intervention areas increased from 477,316 (26%) during 1989-90 (the first full year of the project) to 784,132 (40%) during 1990-91. Through February 20, 1992, an estimated 935,000 (48%) doses have been administered during 1991-92.

Vaccination coverage levels, based only on demonstration-provided vaccine, were 22%-42% among the sites in 1989-90 and 39%-57% in 1991-92 (as of February 20, 1992). Because some Medicare beneficiaries may receive influenza vaccine from sources other than the demonstration, surveys of a sample of Medicare beneficiaries have been performed each season since 1988-89 to permit accurate estimation of vaccine coverage in each intervention and control site. Survey coverage estimates have increased since 1989-90. For 1990-91, survey estimates indicated that coverage levels at six of the 10 intervention sites exceeded 50%, and two intervention sites exceeded 60%. In contrast, in control sites with no enhanced vaccine-delivery or promotion activities, approximately 40% of Medicare beneficiaries surveyed every year had been vaccinated.

Reported by: P Lesniak, Maricopa County Dept of Health Svcs, Phoenix. K McMahon, Illinois Dept of Public Health. R Schmitz, PhD, D Kidder, PhD, A Hassol, A Schwartz, Abt Associates, Inc, Cambridge, Massachusetts; P Etkind, MPH, M Simon, MPH, Massachusetts Dept of Public Health. N Fasano, MS, Michigan Dept of Public Health. W Barker, MD, B Lewis, FM LaForce, MD, Univ of Rochester Medical Center, New York. B Laymon, North Carolina Dept of Environment, Health, and Natural Resources. L Periso, Ohio Dept of Health. R Toth, MPH, Oklahoma State Dept of Health. E Luczak, Allegheny County Health Dept, Pittsburgh. H Gonzalez, San Antonio Metropolitan Health District, San Antonio, Texas. Office of Research and Demonstrations, Health Care Financing Administration. Div of Immunization, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Vaccination programs have substantially reduced the incidence of vaccine-preventable diseases among children, but many older adults remain at risk each year for influenza and its complications because they are inadequately immunized. Adult vaccination has been difficult to implement, in part because 1) no comprehensive vaccine-delivery systems exist in the public and private sectors; 2) although statutory requirements exist for vaccination of children, no such requirements exist for adults; 3) reimbursement mechanisms and coverage by third-party payors are limited in the public and private sectors; and 4) vaccination programs have not been established in most settings where adults congregate (e.g., the workplace). However, some public programs have overcome these barriers and achieved substantial success (e.g., the Hawaii Pneumococcal Disease Initiative (CDC, unpublished data, 1990) and influenza and pneumococcal vaccine programs in California (1)).

Previous studies have documented effective strategies to enhance influenza-vaccination rates and reduce influenza-related morbidity and health-service use (3,4). In addition, influenza vaccination of older persons has been cost-effective (5,6). The Medicare Influenza Vaccine Demonstration has achieved one of its objectives by demonstrating that provision of influenza vaccine can be increased among Medicare beneficiaries. The primary reason for success of the demonstration in vaccine delivery is use of focused intervention techniques to overcome the absence of a comprehensive delivery system, limited reimbursement mechanisms, and lack of vaccination programs where adults congregate. No statutory requirements were necessary to implement this program.

Analyses of the cost-effectiveness of influenza vaccination have not yet been completed. The final report will summarize several cost-effectiveness estimates (e.g., vaccination costs compared to costs saved for inpatient, outpatient, and convalescent care, including analysis of all costs incurred regardless of payor and those costs exclusive to the Medicare program). Unless the demonstration shows that influenza vaccination is not cost effective, it will become a covered Medicare benefit for approximately 32 million beneficiaries, beginning 30 days after the final report is submitted to Congress.

In 1990-91 two of 10 demonstration sites reached the year 2000 national health objective of 60% vaccination coverage among noninstitutionalized persons greater than or equal to 65 years of age (objective 20.11) (7). For the 1991-92 influenza season, combined coverage for the 10 intervention sites (including vaccine administered outside of the program) might exceed 60%. Increasing vaccine use among adults and reaching the year 2000 national health objectives for vaccination will continue to require multifaceted strategies such as those employed in this demonstration.


  1. CDC. Successful strategies in adult immunization. MMWR 1991;40:700-3,709.

  2. Buffington J, Bell K, LaForce FM, et. al. A target-based model for increasing influenza immunizations in private practice. J Gen Intern Med 1991;6:204-9.

  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. Fedson DS. Influenza prevention and control; past practices and future prospects. Am J Med 1987;82(suppl 6A):42-7.

  5. Riddiough MA, Sisk JE, Bell JC. Influenza vaccination: cost-effectiveness and public policy. JAMA 1983;249:3189-95.

  6. Patriarca PA, Arden NH, Koplan JP, Goodman RA. Prevention and control of type A influenza infections in nursing homes: benefits and costs of four approaches using vaccination and amantadine. Ann Intern Med 1987;107:732-40.

  7. 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; DHHS publication no. (PHS)91-50213.

    • For nine states, matched intervention and control areas were within the same state; the entire state of Kansas was the control area for Oklahoma.

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