RESEARCH IN IMMUNIZATION

School-Located Influenza VaccinationWith Third-Party Billing:

Outcomes, Cost, and ReimbursementAllison Kempe, MD, MPH; Matthew F. Daley, MD; Jennifer Pyrzanowski, MSPH;Tara Vogt, PhD, MPH; Hai Fang, PhD, MPH; Deborah J. Rinehart, PhD, MA;Nicole Morgan, MHA; Mette Riis, BS, BSN, MSW; Sarah Rodgers, BA;Emily McCormick, MPH; Anne Hammer, BA, BSN; Elizabeth J. Campagna, MS;Deidre Kile, MS; Miriam Dickinson, PhD; Simon J. Hambidge, PhD, MD;Judith C. Shlay, MD, MSPH

From the Children’s Outcomes Research Program, The Children’s Hospital, Aurora, Colo (Dr Kempe, Dr Daley, Ms Pyrzanowski, and DrDickinson); Department of Pediatrics (Dr Kempe, Dr Daley, and Dr Hambidge), Colorado Health Outcomes Program (Dr Kempe, MsCampagna, and Ms Kile), Department of Health System, Management and Policy (Dr Fang), Department of Family Medicine (Dr Dickinsonand Dr Shlay), University of Colorado, Aurora, Colo; Institute for Health Research, Kaiser Permanente, Denver, Colo (Dr Daley and MsMcCormick); National Center for Immunization and Respiratory Diseases (Dr Vogt), Public Health Prevention Services (Ms McCormick),Centers for Disease Control and Prevention, Atlanta, Ga; Health Services Research, Denver Health, Denver, Colo (Dr Rinehart); PhysicianBilling (Ms Morgan), Denver Public Health (Ms Riis, Ms Rodgers, Ms McCormick, Dr Hambidge, and Dr Shlay), and Community HealthServices (Ms Hammer and Dr Hambidge), Denver Health, Denver, ColoDr Daley received an honorarium from McGraw-Hill publishers for writing a textbook chapter on immunizations.The other authors declare that they have no conflict of interest. The findings and conclusions in this article are those of the authors and do notnecessarily represent the views of the US Centers for Disease Control and Prevention.Address correspondence to Allison Kempe, MD, MPH, 13199 E Montview Blvd, Suite 300, Aurora, CO 80045 (e-mail: Allison.Kempe@

childrenscolorado.org). Received for publication October 21, 2013; accepted January 21, 2014.

ABSTRACT

AC

OBJECTIVE: To assess rates of immunization; costs of con-ducting clinics; and reimbursements for a school-located influ-enza vaccination (SLIV) program that billed third-party payers.METHODS: SLIV clinics were conducted in 19 elementaryschools in the Denver Public School district (September 2010to February 2011). School personnel obtained parental consent,and a community vaccinator conducted clinics and performedbilling. Vaccines For Children vaccine was available for eligiblestudents. Parents were not billed for any fees. Data werecollected regarding implementation costs and vaccine costwas calculated using published private sector prices. Reim-bursement amounts were compared to costs.RESULTS: Overall, 30% of students (2784 of 9295) received$1 influenza vaccine; 39% (1079 of 2784) needed 2 dosesand 80% received both. Excluding vaccine costs, implementa-tion costs were $24.69 per vaccination. The percentage of vac-cine costs reimbursed was 62% overall (82% from State Child

CADEMIC PEDIATRICSopyright ª 2014 by Academic Pediatric Association 234

Health Insurance Program (SCHIP), 50% from private insur-ance). The percentage of implementation costs reimbursedwas 19% overall (23% from private, 27% from Medicaid,29% from SCHIP and 0% among uninsured). Overall, 25% oftotal costs (implementation plus vaccine) were reimbursed.CONCLUSIONS: A SLIV program resulted in vaccination ofnearly one third of elementary students. Reimbursement rateswere limited by 1) school restrictions on charging parentsfees, 2) low payments for vaccine administration from publicpayers and 3) high rates of denials from private insurers.Some of these problems might be reduced by provisions inthe Affordable Care Act.

KEYWORDS: cost of care; influenza immunization; reimburse-ment; school-based health care; school-located immunization

ACADEMIC PEDIATRICS 2014;14:234–240

WHAT’S NEW

A school-located influenza vaccine program with third-party billing was feasible and resulted in vaccination of30% of students, but challenges must be overcomebefore this strategy can be widely implemented.

SINCE 2008, INFLUENZAvaccine has been recommendedannually for children$6 months of age1 as a result of chil-dren’s role in propagation of outbreaks and the significant

morbidity of influenza illness.2–9 School-located influenzavaccine (SLIV) programs have been proposed as an impor-tant adjunct to the medical home for accomplishing univer-sal yearly childhood vaccination for several reasons. First,medical homes may not be able to provide the number ofvisits required for universal vaccination in the relativelyshort time required.10 Second, schools provide easy accessto a captive audience of children with the possibility ofhighly efficient vaccine delivery, without the need for apractice visit or loss of work by parents. School-based

Volume 14, Number 3May–June 2014

ACADEMIC PEDIATRICS OUTCOMES, COST, AND REIMBURSEMENT 235

immunization could be less costly than office-based deliv-ery. Schools may also be an important delivery site for chil-dren who lack a regular site of care.11,12 Recent dataindicate support of pediatricians,13–15 parents, andchildren16,17 for school-located influenza delivery. Finally,although SLIV may present challenges for school sys-tems,18,19 the aim of decreasing absenteeism rates alignswell with the educational mission of schools.

A number of school-located influenza vaccine programshave been described.18,20–26 However, most previousprograms relied on donated influenza vaccine18,22–24 orfocused efforts only on Vaccines for Children (VFC)-eligible children.21 This has limited the scope and sustain-ability of school-located delivery programs. Unless federalor state funds support school-located vaccination, billing ofthird-party payers may be necessary for the viability ofschool-located vaccine delivery.

Our study objectives were to evaluate an SLIV programconducted within a public school system by assessing therates of provision of first and second influenza vaccinesto eligible children, and assessing the costs of SLIV, theextent of reimbursement from third-party payers, and thepercentage of costs that were reimbursed by third-partypayers.

METHODS

The human subjects review board at the University ofColorado Denver approved this study.

SETTING AND POPULATION

Of the 72 noncharter kindergarten through 6th gradeelementary schools in Denver’s public school district, 20were selected. We included 3 schools that had previouslybeen involved in a school-located vaccine program for vac-cinations other than influenza, plus 17 additional schoolsselected to be representative of schools in the district,based on quadrant of the city, percentage of studentseligible for free and reduced-price lunch, and the percent-age of minorities (as reported by students’ guardian). Oneschool dropped out early in the process, leaving 19 partici-pating schools.

SLIV PROGRAM

The SLIV program was developed jointly by a commu-nity vaccinator, consisting of the Denver Public Health andDenver Community Health Services, and Denver PublicSchools during 2008–2009 and subsequently initiated dur-ing the 2009–2010 school year. Modifications were madeon the basis of the first year, including moving the consentprocess to school registration and beginning clinics earlierin the school year, and the programwas then studied duringthe 2010–2011 school year, when the program was consid-ered mature.

Community vaccinator personnel delivered influenzavaccine to students who had provided consent at partici-pating schools and billed third-party payers. Two clinicswere held at each school, and both live attenuated influenzavaccine (LAIV) and trivalent inactivated vaccine (TIV)

were offered. At all schools, information about the SLIVclinics and consent packets were included in school regis-tration materials, distributed at school registration, whichall parents are required to attend, and sent home to parentsduring the first 2 weeks of school. Community vaccinatorpersonnel attended registrations and back-to-school activ-ities to answer questions. Registration packets included atelephone number for parents to call with questions aboutthe program or eligibility, including a language line withSpanish speakers at each school. The consent formsrequested health insurance information, a copy of thechild’s vaccine record to determine number of influenzadoses needed, and information related to eligibility forthe VFC program. For each child who returned a consentform, the Colorado Immunization Information Systemand verification of insurance were checked before thescheduled clinic date. On the day of the clinic, duringschool hours, students were escorted by grade from theirclassroom to the SLIV clinic. Children received LAIV un-less there was a medical contraindication or a specificrequest for TIV by their parent. VFC vaccine was availablefor eligible students. Vaccines administered were enteredinto the Colorado Immunization Information System.After each clinic, community vaccinator staff billed each

student’s insurance companies for the vaccine and theadministration fee. Bills were resubmitted multiple timesif necessary. On the basis of the school district’s policy,parents were not billed for vaccine or administration feesif claims were denied, for any copays or deductibles, orif the family was uninsured. We extracted reimbursementdata and reasons for denial from the community vaccina-tor’s billing system 120 days after the date that informationwas entered into the billing system.

COST ASSESSMENTS

IMPLEMENTATION COSTS

We estimated implementation costs from the point ofview of the community vaccinator and included all costsof delivering the vaccine traditionally billed for underadministration charges. Implementation cost data includedadministrative accounting data and the time program staffspent on program activities. Accounting data and invoicesfrom the community vaccinator documented nonpersonnelcosts, including photocopying, printing of consent formsand promotional materials, postage, office supplies, medi-cal supplies, cell phone use, language line use, translationalservice costs, and the purchase of a portable printer, as wellas amortized costs for use of a project van and refrigerator.Several methods were used to describe the time staff

spent on clinic activities. These included: 1) direct ob-servation of essential pre- and postclinic activities fora sample of clinics; 2) a clinic sign-in sheet, which capturedthe time all staff began and stopped working at each clinic;3) tracking of time by staff for time spent obtaining missinginformation from each consent form; 4) time school para-professionals spent preparing for each clinic (collected byresearch staff during each clinic); and 5) time estimates re-ported for several key activities that were not otherwise

236 KEMPE ET AL ACADEMIC PEDIATRICS

assessed. The Family Educational Rights and PrivacyAct27,28 places restrictions on the release of studentinformation to outside entities; therefore, schoolpersonnel needed to make initial contacts with studentsand families before signed consent was provided.To facilitate this, the community vaccinator paid theschool system to hire paraprofessionals to support theconsent process and other SLIV activities. Theparaprofessionals’ time was therefore included as part ofthe implementation cost. Additionally, we applied a 10%overhead cost, the standard agency indirect rate used forservices conducted at a location other than an agencyowned or operated facility, to the overall communityvaccinator direct costs.

VACCINE COSTS

As a result of proprietary pricing, variation in vaccinecost across organizations and to increase the generaliz-ability of our data nationally, the cost of vaccines was as-certained from the US Centers for Disease Control andPrevention (CDC) vaccine price list as of July 2011.29 Vac-cine cost for the private sector was $11.17 for TIV and$19.70 for LAIV. Because VFC vaccine was obtained atno cost to the community vaccinator, VFC vaccine wasnot included when calculating vaccine costs.

VACCINE AND ADMINISTRATION BILLING CHARGES

The amount billed for LAIV or TIV followed the com-munity vaccinator’s internal policies, which was $20 foreither vaccine and $12 for the associated administrationfee from all payers. Because Colorado Medicaid policiescap reimbursement at $6.50 for vaccine administrationfees for patients younger than 20 years of age,30 this meantthat administration fees could only be partially reimbursedfor children with Medicaid.

OUTCOMES

Primary outcomes included receipt of$1 influenza vac-cine, receipt of 2 vaccines if the child was eligible and totalcosts per vaccine delivered, as well as percentage of costsreimbursed overall and within each insurance type for vac-cine and vaccine implementation costs and the percentageof total costs covered by reimbursement.

ANALYSIS

Descriptive statistics were used to characterize SLIVparticipation. Characteristics of SLIV participants versusnonparticipants were compared by the Pearson chi-squaretest of association. All analyses were performed by SAS9.3 (SAS Institute, Cary, NC).

Community vaccinator implementation costs were cate-gorized and summed by pre-, post-, and day-of-clinic costs.To determine personnel costs, staff time data were multi-plied by the agency median salary for the appropriate jobtitle plus fringe benefits. We calculated an implementationcost per vaccination by dividing all implementation costs(the sum of pre-, post-, and day-of-clinic costs plus 10%overhead costs) by the total number of vaccinations pro-

vided at all clinics. Vaccination costs were calculated bymultiplying the CDC vaccination price for LAIV or TIVby the number of each type of vaccine delivered. Costsrelated to the evaluation of the program were excluded.We determined the percentage of implementation, vaccine,and combined implementation and vaccine costsreimbursed by insurance types and then determined thepercentage of total costs that were covered by the totalreimbursement.

RESULTS

CHARACTERISTICS OF PARTICIPATING SCHOOLS AND

PROGRAM PARTICIPANTS

All students enrolled at participating schools as ofOctober 1, 2010, were included in the study, including9295 total students, the majority of whom were Hispanicand qualified for free and reduced-price lunch. Table 1shows characteristics of the participating schools and stu-dent bodies. Table 2 shows that students who participatedin the SLIV program differed from nonparticipants withrespect to ethnicity and primary language of their parents.Among participants, 53% were covered by Medicaid, 28%were uninsured, 11% had private insurance, and 8% werecovered by the State Child Health Insurance Plan (SCHIP).Comparable insurance data for nonparticipants were notavailable.

SLIV PROGRAM IMMUNIZATION OUTCOMES

Overall, 30% (2784 of 9295) of students at the 19schools received $1 influenza vaccines. Of the studentswho participated in the SLIV program, 39% (1079 of2784) needed 2 doses, and 80% of these students (862of 1079) received them; 764 received both doses at anSLIV clinic. One percent (n ¼ 42) of participating stu-dents were overvaccinated at either the first or secondSLIV clinic, receiving an unnecessary second or thirddose of influenza vaccine. Ninety-three percent of firstclinic participants received LAIV vaccine, and 7%received TIV.

COSTS AND REIMBURSEMENT

IMPLEMENTATION COST

As shown in Table 3, the majority of the implementationcosts were related to preclinic and day-of-clinic activities,with only approximately 10% of costs related to patientregistration, submission of claims, and follow-up of deniedclaims. The total mean implementation cost per vaccina-tion delivered was $24.69.

VACCINE COST

A total of $13,917.74 was the cost for providing 729 pri-vately purchased vaccines: 52 TIV vaccines at $11.17 and677 LAIV vaccines at $19.70.

REIMBURSEMENT FROM THIRD-PARTY PAYERS

As shown in Table 4, the percentage of claims that werereimbursed at all (for amounts greater than $0) varied

Table 1. Characteristics of 19 Schools That Participated in SLIV

Program*

Characteristic Median (min, max)

Student enrollment, n 471 (320, 616)Student body eligible for FRL, % 87 (25, 98)Race/ethnicity, %

Black (not Hispanic) 6 (1, 45)Hispanic 78 (12, 96)White (not Hispanic) 7 (2, 66)Other† 2 (1, 11)

SLIV ¼ school-located influenza vaccination; FRL ¼ free and

reduced-price lunch program.

*Data obtained from Colorado Department of Education, fall 2008

public membership, http://www.cde.state.co.us/cdereval/rv2008pm-

links.htm.

†“Other” includes American Indian or AlaskanNative and Asian or

Pacific Islander.

ACADEMIC PEDIATRICS OUTCOMES, COST, AND REIMBURSEMENT 237

considerably by insurance types. SCHIP and Medicaidalmost universally reimbursed something for administra-tion fees, and SCHIP also had high rates of reimbursingfor vaccine costs. However, only approximately half of pri-vate insurance companies paid anything for either the vac-cine or the administration fee. Because the source ofvaccine for Medicaid and uninsured children was theVFC program, no vaccine claims were submitted for theseparticipants. In addition, no administration fee claims werebilled for uninsured students.

PERCENTAGE OF COSTS REIMBURSED

As shown in Table 4, the percentage of total providercosts reimbursed was low for all groups, with the highestrates for SCHIP insurance and lowest for Medicaid. The to-

Table 2. Comparison of Participants and Nonparticipants in SLIV

Program*

Characteristic

Participant, %

(n ¼ 2784)

Nonparticipant, %

(n ¼ 6511) P

Male gender 49 52 .04Race/ethnicity <.001

Black, not Hispanic 6 12Hispanic 74 55White, not Hispanic 16 29Other 4 4

Age (as of secondclinic date)

.03

<9 y 68 66$9 y 32 34

Grade .03ECE–kindergarten 28 261st–3rd grade 46 464th–6th grade 26 28

Correspondencelanguage

<.001

English 43 66Spanish 56 33Other 1 1

SLIV ¼ school-located influenza vaccination; ECE ¼ early child-

hood education.

*Demographic data for all students enrolled at participating

schools was provided by Denver Public Schools’ Department of

Technology Services collected through the school districts’ elec-

tronic student information system, Infinite Campus.

tal percentage of costs reimbursed, which took into accountthe lack of any administration fee cost reimbursement foruninsured children, was only 25%. Reasons for denial ofpayment for administration or vaccine fees from private in-surance companies at least 120 days after claims submis-sion included the following: services provided out ofnetwork (34% of administration fees; 28% of vaccinefees), patient had a deductible (12%; 30%), charges ex-ceeded the fee schedule (11%; 4%), the patient was notcovered (11%; 9%), the claim was submitted improperly(3%; 2%), services were not covered under the patient’splan (2%; 2%), or the benefit for this service was includedwith payment for another routine procedure (2%; 0.4%).For 25% of unpaid claims of both types, a reason fornonpayment was not given.

DISCUSSION

Although school-located delivery of influenza vaccineappears to be a potentially ideal way to deliver vaccine effi-ciently to a captive audience of school-age children, suchprograms have generally either been limited to childrenwho are eligible for VFC vaccine or have been conductedwith donated vaccine. To our knowledge, our study was thefirst to assess a school program that was made available toall students that included billing of third-party payers. Ourresults show that the program reached almost one third ofthe student population of 19 urban elementary schools,and children who required a second dose received it at avery high rate. Although most children who accessed theprogram were either uninsured or had Medicaid insurance,one fifth of them had either private or SCHIP insurance.There was insufficient recovery of costs for the program,likely as a result of a combination of insufficient charging($12) for administration costs from all insurers by the com-munity vaccinator, inability to charge administration feesfor patients without insurance, low rates of any reimburse-ment by private insurers, and a state cap for Medicaid reim-bursement for vaccine administration ($6.50) that was wellbelow the estimated implementation costs derived in thisstudy ($24.69).School-located influenza vaccine programs have been

described in elementary, middle, and high schools, withthe highest rates of participation by elementary school–age children.18,20–22 An average rate of vaccination atSLIV programs of 21.5% has been reported for children ingrades kindergarten through 5th grade,20 although a fewstudies have demonstrated rates for elementary school chil-dren of 47%22 and 56%.18 The current program, involvingcollaboration between a school system and a communityvaccinator, was successful in reaching more children thanmost previously published reports and was especially suc-cessful in accomplishing full vaccination in those childrenwho needed 2 doses. Participants weremore likely to beHis-panic, and the majority were insured by Medicaid or unin-sured, suggesting that this type of program may beparticularly helpful for minority and lower-income students.Notably, almost all previously published reports of SLIV

programs have involved the delivery of donated vaccine

Table 3. SLIV Program Implementation Costs From Perspective of Community Vaccinator*

Time Activities/Materials to Conduct SLIV Program Cost per Vaccine % of Cost

Preclinic Community vaccinator: printing, distributing, collecting, and reviewing consentforms, updating vaccinators’ vaccine registry, printing vaccinerecommendations, office/administration supplies, equipment,communication with parents, translation resources

$8.74 35%

School paraprofessional: distributing, collecting, and reviewing consent forms,communicating with parents†

$2.16 9%

Day of clinic Community vaccinator: RN hours, clerical hours, transportation, medicalsupplies, entering given vaccines into vaccine registry

$7.98 32%

School paraprofessional: assist with clinic, such as escorting student to andfrom class†

$1.40 6%

Postclinic Community vaccinator: registering patients, submitting claims, follow-up ofdenied claims

$2.49 10%

Indirect costs‡ Community vaccinator: 10% of total direct community vaccinator costs $1.92 8%Total implementation costs . $24.69 100%

SLIV ¼ school-located influenza vaccination.

*Vaccine cost is not included.

†Pay for paraprofessionals hired by the school district to support SLIV program activities was funded by the community vaccinator through a

subcontract.

‡Indirect costs are not applied to community vaccinator subcontract costs.

238 KEMPE ET AL ACADEMIC PEDIATRICS

from a manufacturer18,22–24 or use of vaccine available topublic health departments for children eligible for VFC orfrom the Section 317 program.21 Some authors reportbilling for vaccine or its administration, but they have notpublished information about the process or its success.20

School-based health centers in which comprehensive healthservices are delivered within a school often bill third-partypayers.31,32 However, such centers are stable health caredelivery structures rather than community vaccinatorscoming into a school; therefore, their billing experienceshave marginal relevance to SLIV programs. The currentprogram demonstrated that school-based third-party billingfor both vaccine and implementation costs was feasible, butproblems with reimbursement will need to be solved beforeit can be financially solvent. Reimbursement was greatlylimited by the low administration amount billed by the com-munity vaccinator, based on internal policies, and the lowreimbursement cap for administration ($6.50) by Medicaidin Colorado. State reimbursement rates in 2007 ranged from

Table 4. Percentage of Claims and Costs Reimbursed by Insurance Ca

Characteristic Private/HMO SCHIP

No. of claims 455 274Vaccine claims reimbursed >$0 49% 79%Administration claims reimbursed

>$0†56% 92%

Total costs, $§ $19,873.31 $12,043.4Vaccine cost reimbursedjj 50% 82%Implementation cost reimbursed{ 23% 29%Total cost reimbursed§ 35% 52%

HMO ¼ health maintenance organization; SCHIP ¼ State Health Insu

*Vaccine claims and costs not applicable for Medicaid and uninsured

†Colorado Medicaid reimbursed $6.33 per administration claim althou

‡Parents of uninsured students were not billed vaccine administration

§Total costs include vaccine and implementation costs for private and

uninsured categories.

jjVaccine costs calculated using the 2011 US Centers for Disease Co

{Implementation costs are equal to number of claims multiplied by $2

$2 to $17.86 (mean $9.17, median $9.23).33 In addition,school policy did not permit the program to charge parentsfor administration of vaccine to children with no insurance.The percentage of administration fee and vaccine claimsthat were denied by private insurance companies becausethey were “out of network” also limited reimbursement.Our data are difficult to comparewith other recent estimatesof costs of school-located influenza delivery because previ-ous reports have not separated vaccine and administrationcosts and have not examined reimbursement.21,34,35

However, the implementation cost we calculated, $24.69per vaccine, is within the 2 published estimates ofadministration costs for delivery of a vaccine in privatepractice in 2009, $11.8336 and $29.77.37 Therefore, if theidentified reimbursement issues can be solved, school-located delivery will likely not increase costs to insurersover office-based delivery.Some of the problems with reimbursement could be

alleviated by provisions of the Patient Protection and

tegory

Insurance Type

Medicaid (VFC) Uninsured (VFC) Total

1846 973 3548.* .* 60%97% .‡ 89%

4 $45,577.74 $24,023.37 $101,517.86.* .* 62%27% 0% 19%27% 0% 25%

rance Program for Children; VFC ¼ Vaccines for Children.

categories as a result of VFC eligibility.

gh cap is $6.50.

fees.

SCHIP categories and only implementation costs for Medicaid and

ntrol and Prevention vaccine price list.

4.69.

ACADEMIC PEDIATRICS OUTCOMES, COST, AND REIMBURSEMENT 239

Affordable Care Act and the Health Care and EducationReconciliation Act of 2010, which together are referredto as the Affordable Care Act.38,39 If more children areinsured, administration fees should more often bereimbursed. Mandatory first-dollar coverage for preven-tive services such as immunizations could mean nodeductibles and no refusals based on not being acovered benefit.38,39 However, the act stipulates thatsuch services be provided “in network,” which willnecessitate negotiations with payers to include theprovision of vaccines by community vaccinators orschool nurses. In addition, the Affordable Care Act willincrease Medicaid payments for vaccine administrationwhen provided by certain primary physicians in 2013and 2014 to the Medicare or VFC regionalmaximum,38–40 whichever is lower. If this increasebecomes permanent, this level of reimbursement wouldcome close to covering our calculated implementationcosts per vaccine. Finally, collaborative agreementscould potentially be made with health maintenanceorganizations or managed care organizations to decreasepayment denials for “out of network” services. It isimportant to note, however, that lower income childrenwho are not Medicaid eligible and remain uninsured,and children without legal status may not benefit fromprovisions of the Affordable Care Act.

There are some limitations to the data presented here.The student populations at the schools studied were pri-marily from minority racial and ethnic and low-incomegroups. Participation in SLIV clinics could differ amongstudents from different backgrounds. Some of the assess-ments of cost were measured in a subset of clinics andextrapolated to others and some assessments relied onlogs rather than direct observation and may not havebeen precise. We captured and included the time spentby school paraprofessionals hired by the project; however,other school staff support may have contributed time, andwe could not accurately assess their time in our cost esti-mate. In addition, we could not determine the cause of de-nied claims in approximately a quarter of cases.Reimbursement for vaccine administration would be sub-stantially higher in states with a higher Medicaid cap,and potentially in populations with more privately insuredstudents. Finally, because vaccination rates for entire stu-dent populations are not available, we could not determinewhether the SLIV program increased immunization ratesor simply shifted the location of receipt.

Our data demonstrate both the feasibility of a school-located influenza vaccine program with third-party billingand the challenges still facing such an approach. Some ofthese challenges could be ameliorated by health insurancereforms related to the Affordable Care Act. Remaininglogistical and financial barriers might be greatly reducedby using a collaborative approach to influenza vaccine de-livery, with private provider groups, public health depart-ments, and schools working together to accomplishdelivery to school-age children at school. As highlightedrecently by the Institute of Medicine,41 the integration ofefforts from private and public health delivery sectors

will be necessary to achieve substantial improvements inpopulation health. Because prevention of influenza inschool-age children is such an important deterrent tocommunity-wide epidemics, school-located influenzavaccination is an ideal testing ground for the developmentof such collaborations within a community.

ACKNOWLEDGMENTS

This investigation was supported and funded by Cooperative

Agreement 1U01P000199 from the Centers for Disease Control and Pre-

vention.

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