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Physician Vaccination Referral Practices and Vaccines for Children -- New York, 1994

Although vaccinations are among the most effective preventive public health measures available, many children are not vaccinated on time (1). One identified barrier to timely vaccination is referral of children by primary-care physicians to other medical settings for vaccination (2). This report summarizes a survey by the New York State Department of Health of vaccination referral practices among New York physicians and describes the implementation in New York of Vaccines for Children (VFC), a national program making federally purchased vaccines available at no cost to health-care providers for administration to eligible children (3).

During April 1993, a random sample of 1137 licensed pediatricians and family-practice physicians (from a total n=5392) in New York were surveyed by mail about vaccination practices. Of 752 (66%) responses, 502 (67%) were from actively practicing primary-care physicians. Of these, 250 (50%) referred all or some of their patients elsewhere for vaccinations. Of referring physicians, 228 (91%) referred patients to a local health department clinic; 109 (44%) had increased the number of patient referrals during 1983-1993, while seven (3%) had decreased referrals. In addition, 63 (25%) reported that the number of well-child-care visits had decreased during 1983-1993, while five (2%) reported increases during that time. Of the 250 referring physicians, 246 provided reasons for referral and rated those reasons as "very important," "somewhat important," or "not important" (Table_1). Financial hardship was a "very important" reason for referral for 217 (88%) of those surveyed; the lack of vaccination coverage by private insurance was "very important" for 132 (54%). Physicians also were asked whether the government should underwrite the cost of mandatory vaccinations. Overall, 409 (54%) respondents indicated that some or all of the costs of childhood vaccination should be underwritten.

Since October 1, 1994, free vaccine has been available to VFC participating providers in New York. Categories of federally eligible children aged less than 19 years include those on Medicaid, those who are uninsured, those who are underinsured who visit federally qualified health centers, and American Indians/Alaskan Natives. New York also provided free vaccine to underinsured children who receive care in any medical setting and any child served at a local health department.

Medical-care providers were recruited for VFC through articles published in professional organization newsletters and by mailing of registration packets to licensed pediatricians, family physicians, osteopathic physicians, and medical facilities. As of December 27, 1994, a total of 1378 physician practices in New York (including at least 1972 individual physicians and at least 362 health-care facilities) were participating in VFC.

To determine the extent of enrollment by Medicaid providers, the list of VFC enrollees was compared to a list of providers who billed Medicaid for childhood vaccines during federal fiscal year 1993. Of 2169 physicians who billed Medicaid for childhood vaccines in 1993, a total of 1213 (56%) had enrolled. Among the 166 physicians who submitted a minimum of 1000 claims for individual vaccines, 143 (86%) had enrolled, while 653 (68%) of 956 physicians not yet enrolled had submitted fewer than 50 claims.

In September 1994, the New York State Department of Health conducted a telephone survey of health-care providers who had returned registration forms and declined participation in the program to determine reasons for nonparticipation and to guide future recruitment efforts. Of the 41 physicians who had declined, 29 (71%) were contacted. Of these, five (17%) were retired, five (17%) did not accept patients aged less than 19 years, six (21%) were subspecialists or in academic medicine and did not provide vaccinations, six (21%) indicated that most of their patients would not be eligible, one (2%) had multiple reasons for not registering, and the six (21%) with patients who could benefit from VFC agreed to register as a result of the phone call.

From September 15, 1994 (the first date vaccines could be ordered), through December 27, 1994, a minimum of 2,496,000 doses of vaccine had been ordered and approximately 2,456,000 doses were shipped to VFC participants. The average time between placement of orders and receipt of vaccine by providers was 1 week.

Reported by: HG Cicirello, MD, GA Bunn, DR Lynch, SC Meldrum, MS, GS Birkhead, MD, D Morse, MD, State Epidemiologist, New York State Dept of Health. S Freidman, MD, N Jenkusky, MPH, New York City Dept of Health. EE Schulte, MD, Albany Medical Center, Albany, New York. National Immunization Program, CDC.

Editorial Note

Editorial Note: In the United States, approximately 2 million children need one or more doses of recommended vaccines (4). In a 1993 retrospective survey of children entering kindergarten in New York, only 53% had been appropriately vaccinated with the recommended vaccines by age 2 years (5). Important barriers to timely vaccination include missed opportunities to vaccinate at each health-care visit, inconvenient clinic hours, inadequate parental awareness of the need for timely vaccination, inadequate vaccination tracking, the costs of vaccines, and the referral of children from the private sector to the public sector. This report demonstrates that vaccination referrals, in part attributable to vaccine costs, are common among New York primary-care providers. Implementation of VFC is expected to reduce these financial barriers.

The actual number of VFC participants in New York probably is underestimated by VFC enrollment figures because many physicians work in facilities or in group practices where only the physician-in-chief is registered in the program. In addition, the impact of the program on vaccination coverage and overall occurrence of vaccine-preventable diseases cannot be determined yet. However, VFC has allowed New York to increase provision of vaccine to more children in primary-care settings where they first seek care. In states where vaccines have been made available for all children, vaccination rates of preschoolers are approximately 10% higher than the national average (AG Holtmann, University of Miami, unpublished data, 1993).

The Childhood Immunization Initiative (CII) has designated vaccination of preschool-aged children a national priority and has established 1996 and year 2000 goals of vaccinating at least 90% of children by age 2 years with the recommended number of doses of diphtheria and tetanus toxoids and pertussis, polio, Haemophilus influenzae type b, hepatitis B, measles, mumps, and rubella vaccines. The five strategies of CII, which address both financial and nonfinancial barriers to vaccination, are to 1) improve the delivery of vaccines; 2) reduce the cost of vaccines for parents (VFC); 3) enhance awareness, partnerships, and community participation; 4) monitor vaccination coverage and disease; and 5) improve vaccines and their use. VFC, as an integral part of this initiative, will assist physicians and other health-care providers in reaching these national goals.


  1. NCHS. Health, United States, 1993. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994; DHHS publication no. (PHS)94-1232.

  2. Bordley WC, Freed GL, Garrett JM, Byrd CA, Meriwether R. Factors responsible for immunization referrals to health departments in North Carolina. Pediatrics 1994;94:376-80.

  3. CDC. Vaccines for Children program, 1994. MMWR 1994;43:705.

  4. CDC. Vaccination coverage of 2-year-old children -- United States, 1993. MMWR 1994;43:705-9.

  5. Hamburg BG, Dowling TP, Kramer JI, Randles RH, Rodewald LE. Immunization of pre-school children. New York: New York State Public Health Council, Ad Hoc Immunization Committee, March 1993.

Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Reasons for vaccination referral by physicians *, by importance -- New York,
                             Very important    Somewhat important    Not important
                             --------------    ------------------    -------------
Reason                        No.     (%)         No.     (%)         No.    (%)
Financial hardship
  for patient                 217     (88)        14      ( 6)        15    ( 6)
Private insurance not
  covering vaccinations +     132     (54)        56      (23)        58    (24)
Free vaccine to physicians
  discontinued by
  health department &         110     (45)        34      (14)       102    (41)
Vaccine purchase costs
  for physician                94     (38)        56      (23)        96    (39)
Insufficient Medicaid
  reimbursement                74     (30)        43      (17)       129    (52)
Vaccine availability           36     (15)        42      (17)       168    (68)
Vaccine-related liability      24     (10)        31      (13)       191    (78)
* N=246 of 250 physicians who reported referring patients elsewhere for vaccinations.
+ As of April 1994, all New York State-regulated major medical health insurance policies, exclu-
  sive of self-insured entities, were required to cover all childhood vaccinations.
& In 1986, the New York State Department of Health discontinued distribution of free vaccine to
  any physician through county health departments.
Source: New York State Department of Health.

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