Guest Commentary: Vaccine Hesitancy Leading to Lower Immunization Rates

Ruth S. Gubernick, MPH

I am the proud grandmother of a 5-month-old granddaughter whose parents are having her immunized by her pediatrician, according to the Recommended Immunization Schedule, approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).

Recent articles and a national survey are reporting, however, that at least one out of every 10 parents in this country are not following this recommended schedule and are opting out of immunizing their children either on time or at all. Most of these parents are college-educated professionals. Some of these children will be the playmates of my granddaughter.

Vaccine hesitancy is resulting in lower immunization rates in the U.S. today. This year alone, we've had outbreaks of whooping cough and measles in several U.S. communities. Those diseases are only a plane ride away. Several people incubating measles flew into Newark, NJ earlier this year coming in contact with young families in several communities. The un/under-protected infants and children in those communities without high immunization rates or community/herd immunity were especially at risk of disease.

Parents don't want the government or anyone else to make those decisions for their children. I get that. But the problem is where they are choosing to get their information about vaccine safety. It's often the talking heads on TV and Internet bloggers with misinformation, rather than science-based research. I'm in favor of individual rights but their decisions for their own children can adversely impact my granddaughter, who is not yet old enough to be protected against diseases such as measles or chickenpox.

As a public health professional, I see immunizations as a societal responsibility, to protect those who are too young or otherwise unable to receive these recommended childhood immunizations against 14 potentially life-threatening vaccine preventable diseases. Parents who hold "pox parties" or share "lolly-pox" with their infected child's saliva or swabs dabbed with fluid from their child's pox with other families, rather than have their children immunized, make me crazy. Natural disease is not less risky than a vaccine!

I recently piloted an online course that I designed and built for the JSPH Teaching/Learning Seminar required for my doctoral program. It is about immunizations and targets college-educated professionals who are new parents. My students reported that video clips of parents telling their own stories had the most impact on them. I introduced the course with How safe are we? The Role of Vaccines in Protecting your Community ( http://www.youtube.com/watch?v=hsDU35G477E&feature=youtu.be ). It opens with a mom sharing how she felt about unknowingly infecting her newborn with Pertussis. Share these stories with the families that you care for and care about who may be vaccine hesitant. As a grandparent and population health advocate and student, I thank you.

Ruth Gubernick is a JSPH doctoral student.

What a year!!!

As I reflect on 2011, from a health policy perspective, it has been quite a year indeed. Berwick is out, ACOs are in, and costs continue to rise. Employers are trying everything and corporate wellness and prevention is the "new green". The lines separating payers, providers and purchasers are blurring every single day as insurance companies buy doctor practices and hospitals too!! The New England Journal says Disease Management doesn't work and everyone believes one study based on the sickest Medicare patients only. It is increasingly difficult to separate out the "truth" from the background noise, especially as the noise gets louder and louder.

Personally, I am really looking forward to 2012 and the ongoing struggle to make health care more accountable, transparent, safer and more cost effective. I am confident that the Jefferson School of Population Health will continue to provide leadership in its research, teaching and dissemination agenda. Our journals, this BLOG, our Medpages column, our national conferences, continue to resonate with the key opinion leaders in healthcare across the nation.

I hope that you will continue to turn to us for informed opinions and solid evidence too about what is working and what is not. One thing surely still remains the same regarding the reform efforts and that is of course " No Outcome--No Income". I am convinced that the future belongs to groups that can make this pithy statement a reality for everyday practice. We are always interested in your views too. DAVID NASH

Guest Commentary: CMS Continues to Raise Stakes on Quality Measurement

This is the third in a series of blog postings summarizing issues, methods and results from current research in the Center for Value in Healthcare. We will be presenting a JSPH Forum entitled “Translating Research into Policy and Practice” on January 11th, 2012 with more details of the Center’s work.

Valerie P. Pracilio, MPH, Project Manager for Quality Improvement
and Bettina Berman, RN, Project Director for Quality Improvement

Measuring quality of care in the inpatient setting has been a staple of the healthcare environment for several years. Hospitals are penalized financially if they do not report data to the Centers for Medicare and Medicaid Services (CMS) on certain conditions, so solid measurement criteria is a necessity.

CMS’s desire to increase accountability at the provider-level created a need to assess quality in outpatient settings. In 2006, a governmental mandate led to the establishment of the Physician Quality Reporting System (PQRS) to incent eligible professionals who satisfactorily report data on quality measures for services provided to Medicare beneficiaries. Since then, JSPH has been collaborating with Quality Insights of Pennsylvania (QIP) on the development and maintenance of the measures included in the PQRS program.

Measurement development is a rigorous process that must be supported by solid evidence and must also consider feasibility of application in practice. Through our engagement with the QIP, our team has supported this process through evidence gathering and grading. A Technical Expert Panel (TEP) established for each measure also works with QIP to discuss feasibility of measure application. JSPH plays a part in engaging relevant experts to serve on the panel and presents the evidence to support their decisions. Once the measure development process has concluded, the measures are submitted to the National Quality Forum (NQF) for endorsement and broadly disseminated.

At Thomas Jefferson University, the faculty practice plan, Jefferson University Physicians (JUP), has participated in the PQRS program since its inception. Under the leadership of Dr. David B. Nash, the committee that oversees JUP’s performance improvement activities, the JUP Clinical Care Subcommittee (CCS), decided that participation in this program would be valuable to advance quality of care. A strong collaboration between the JUP Performance Improvement Team and JUP administration led to successful implementation of the PQRS program in all practices. The team works closely with practice representatives to select measures for submission and provides ongoing education and support for the practices. As a result, JUP has successfully increased physician participation and incentive payments over the past four years since the start of the program.

More accountability is on the way. CMS plans to move from pay for reporting to pay for performance. Beginning in 2013, CMS will publish PQRS data on the Physician Compare website for providers who report on quality measures through the Group Practice Method (GPRO). In 2015, the stakes will be raised even higher when providers’ Medicare payments are adjusted downward if they do not participate in the PQRS program. The question remains – will demand for provider accountability benefit Medicare beneficiaries?

As always, we are interested in your comments.

Guest Commentary: Physician Profiling in Emilia-Romagna Italy: A Tool for Quality Improvement

Vittorio Maio, PharmD, MS, MSPH,
Associate Professor
and Valerie Pracilio, MPH, Project Manager
for Quality Improvemement
Jefferson School of Population Health

This is the second in a series of blog postings summarizing issues, methods and results from current research in the Center for Value in Healthcare. We will be presenting a JSPH Forum entitled “Translating Research into Policy and Practice” on January 11th, 2012 with more details of the Center’s work.

Assessment is part of our daily lives. In school, we apply for admittance; in employment, we are screened before being hired, and once we’re “in,” we are regularly evaluated to ensure that we are performing at a level deemed appropriate. In the Italian Healthcare System a similar approach is being used to engage primary care physicians in quality. Performance data presented to physician teams is the first step in a profiling process. Not only does this help raise their awareness about the level of care they are providing, but it also engages them in discussions with their peers about what they can do to improve.

By definition, physician profiling is an analytic tool used to compare physician practice patterns across quality of care dimensions (American Academy of Family Physicians). The benefit is that it raises provider awareness of quality through feedback to stimulate improvement.

In Italy, primary care, provided by general practitioners (GPs), is the foundation of the Italian National Health Service, which maintains universal coverage to all citizens either free or at minimal charge at the point of service. Traditionally, GPs have worked in solo practices. However, in the last ten years, in an effort to increase coordination of care, the Italian National Health Service has introduced substantial reforms seeking to encourage collaborative arrangements among GPs. In order to build on earlier national reform, the Emilia-Romagna region (a large region located in northern Italy with a population of about 4.6 million inhabitants) passed a law in 2004 that required GPs to join a Primary Care Team (PCT).

In a PCT, GPs, many of whom are in solo practice, act in full autonomy, but are part of clinical networks designed to provide patients with integrated delivery of healthcare. Specifically, in a PCT, GPs are mandated to collaborate and share information, and by means of clinical governance, to engage in improving the quality of healthcare services provided to patients.

To this end, using the regional healthcare administrative database, the Emilia-Romagna region and Thomas Jefferson University began a collaboration to provide PCTs with information about the quality of services delivered to their patients via PCT profiles. GPs discuss the PCT profile data they are presented with their colleagues in their PCT and initiate PDSA cycles of improvement to make changes to their practice accordingly. Through a collective agreement with the region, GPs receive incentives to participate in the activity.

In the U.S., where the mission is not unified as it is in Italy, the focus has been on paying for performance rather than participation. There is something to be said for the focus on participation that has been demonstrated in Italy to invite physicians into the conversation about quality and actively engage in improvement. In the current U.S. healthcare environment, the stakes are being raised and soon the incentives for improving will turn into disincentives for not meeting standards.

Should we be focused on engaging physicians in quality through a non-punitive approach such as the one our colleagues in Italy are using, or continue to expect physicians will meet quality goals if incentivized? We’re interested in your thoughts.