Decline in physician referrals to health department clinics for immunizations: the role of vaccine financing

Am J Prev Med. 2000 May;18(4):318-24. doi: 10.1016/s0749-3797(00)00120-3.


Background: Physicians frequently refer children to health department clinics (HDCs) for immunizations because of high out-of-pocket costs to parents and poor reimbursement for providers. Referrals for immunizations can lead to scattered care. In 1994, two vaccine financing reforms began in New York State that reduced patient costs and improved provider reimbursement: the Vaccines for Children Program (VFC, mostly for those on Medicaid and uninsured) and a law requiring indemnity insurers to cover childhood immunizations and preventive services.

Objective: To measure reported changes in physician referrals to HDCs for immunizations before and after the vaccine financing reforms.

Design: In 1993, a self-administered survey measured immunization referral practices of primary care physicians. In 1997, we resurveyed respondents of the 1993 survey to evaluate changes in referrals.

Setting/ participants: Three hundred twenty-eight eligible New York State primary care physicians (65% pediatricians and 35% family physicians) who responded to the 1997 follow-up immunization survey (response rate of 82%).

Results: The proportion of physicians reporting that they referred some or all children out for immunizations decreased from 51% in 1993 to 18% in 1997 (p<0.001). In 1997, physicians were more likely to refer if they were family physicians (28% vs. 13%,p<0.01), or did not obtain VFC vaccines (29% vs. 13%,p<0.001). According to physicians who referred in 1993, decreased referrals in 1997 were due to the new insurance laws (noted by 61%), VFC (60%), Child Health Plus (a statewide insurance program for poor children, 28%), growth in commercial managed care (23%), Medicaid managed care (19%), and higher Medicaid reimbursement for immunizations that is due to VFC (18%). For physicians noting a decline in referrals, the magnitude of the decline was substantial-60% fewer referrals for VFC-eligible patients and 50% fewer for patients eligible under the new insurance law.

Conclusions: Vaccine financing reforms decreased the proportion of physicians who referred children to HDCs for immunizations, and may have reduced scattering of pediatric care.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Ambulatory Care Facilities
  • Child
  • Child, Preschool
  • Female
  • Health Care Costs
  • Health Care Reform / economics
  • Health Care Surveys
  • Humans
  • Immunization Programs / economics*
  • Immunization Programs / standards
  • Male
  • Multivariate Analysis
  • New York
  • Odds Ratio
  • Practice Patterns, Physicians' / economics*
  • Probability
  • Referral and Consultation / economics
  • Referral and Consultation / statistics & numerical data*
  • Vaccination / economics*