School-Located Influenza Vaccination With Third-Party Billing: Outcomes, Cost, and Reimbursement



      To assess rates of immunization; costs of conducting clinics; and reimbursements for a school-located influenza vaccination (SLIV) program that billed third-party payers.


      SLIV clinics were conducted in 19 elementary schools in the Denver Public School district (September 2010 to February 2011). School personnel obtained parental consent, and a community vaccinator conducted clinics and performed billing. Vaccines For Children vaccine was available for eligible students. Parents were not billed for any fees. Data were collected regarding implementation costs and vaccine cost was calculated using published private sector prices. Reimbursement amounts were compared to costs.


      Overall, 30% of students (2784 of 9295) received ≥1 influenza vaccine; 39% (1079 of 2784) needed 2 doses and 80% received both. Excluding vaccine costs, implementation costs were $24.69 per vaccination. The percentage of vaccine costs reimbursed was 62% overall (82% from State Child Health Insurance Program (SCHIP), 50% from private insurance). The percentage of implementation costs reimbursed was 19% overall (23% from private, 27% from Medicaid, 29% from SCHIP and 0% among uninsured). Overall, 25% of total costs (implementation plus vaccine) were reimbursed.


      A SLIV program resulted in vaccination of nearly one third of elementary students. Reimbursement rates were limited by 1) school restrictions on charging parents fees, 2) low payments for vaccine administration from public payers and 3) high rates of denials from private insurers. Some of these problems might be reduced by provisions in the Affordable Care Act.


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        • Centers for Disease Control and Prevention
        Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008.
        MMWR Recomm Rep. 2008; 57: 1-60
        • Fox J.P.
        • Hall C.E.
        • Cooney M.K.
        • Foy H.M.
        Influenzavirus infections in Seattle families, 1975–1979. I. Study design, methods and the occurrence of infections by time and age.
        Am J Epidemiol. 1982; 116: 212-227
        • Glezen W.P.
        • Couch R.B.
        Interpandemic influenza in the Houston area, 1974–76.
        N Engl J Med. 1978; 298: 587-592
        • Heikkinen T.
        • Silvennoinen H.
        • Peltola V.
        • et al.
        Burden of influenza in children in the community.
        J Infect Dis. 2004; 190: 1369-1373
        • Monto A.S.
        • Sullivan K.M.
        Acute respiratory illness in the community. Frequency of illness and the agents involved.
        Epidemiol Infect. 1993; 110: 145-160
        • Neuzil K.M.
        • Mellen B.G.
        • Wright P.F.
        • et al.
        The effect of influenza on hospitalizations, outpatient visits, and courses of antibiotics in children.
        N Engl J Med. 2000; 342: 225-231
        • Neuzil K.M.
        • Hohlbein C.
        • Zhu Y.
        Illness among schoolchildren during influenza season: effect on school absenteeism, parental absenteeism from work, and secondary illness in families.
        Arch Pediatr Adolesc Med. 2002; 156: 986-991
        • Poland G.A.
        • Hall C.B.
        Influenza immunization of schoolchildren: can we interrupt community epidemics?.
        Pediatrics. 1999; 103: 1280-1282
        • Weycker D.
        • Edelsberg J.
        • Halloran M.E.
        • et al.
        Population-wide benefits of routine vaccination of children against influenza.
        Vaccine. 2005; 23: 1284-1293
        • Rand C.M.
        • Szilagyi P.G.
        • Yoo B.K.
        • et al.
        Additional visit burden for universal influenza vaccination of US school-aged children and adolescents.
        Arch Pediatr Adolesc Med. 2008; 162: 1048-1055
        • Vogt T.M.
        • Wortley P.M.
        Epilogue: school-located influenza vaccination during the 2009–2010 pandemic and beyond.
        Pediatrics. 2012; 129: S107-S109
        • Cawley J.
        • Hull H.F.
        • Rousculp M.D.
        Strategies for implementing school-located influenza vaccination of children: a systematic literature review.
        J Sch Health. 2010; 80: 167-175
        • McCormick E.V.
        • Durfee J.
        • Vogt T.M.
        • et al.
        Physician attitudes regarding school-located vaccinations.
        Pediatrics. 2012; 130: 887-896
        • Keane V.A.
        • Hudson A.R.
        • King Jr., J.C.
        Pediatrician attitudes concerning school-located vaccination clinics for seasonal influenza.
        Pediatrics. 2012; 129: S96-S100
        • Kempe A.
        • Wortley P.
        • O’Leary S.
        • et al.
        Pediatricians’ attitudes about collaborations with other community vaccinators in the delivery of seasonal influenza vaccine.
        Acad Pediatr. 2012; 12: 26-35
        • Kempe A.
        • Daley M.F.
        • Pyrzanowski J.
        • et al.
        School-located influenza vaccination: what do parents think?.
        Acad Pediatr. 2014; 14: 241-248
        • Kelminson K.
        • Saville A.
        • Seewald L.
        • et al.
        Parental views of school-located delivery of adolescent vaccines.
        J Adolesc Health. 2012; 51: 190-196
        • Carpenter L.R.
        • Lott J.
        • Lawson B.M.
        • et al.
        Mass distribution of free, intranasally administered influenza vaccine in a public school system.
        Pediatrics. 2007; 120: e172-e178
        • Fiore A.E.
        • Epperson S.
        • Perrotta D.
        • et al.
        Expanding the recommendations for annual influenza vaccination to school-age children in the United States.
        Pediatrics. 2012; 129: S54-S62
        • Schieber R.A.
        • Kennedy A.
        • Kahn E.B.
        Early experience conducting school-located vaccination programs for seasonal influenza.
        Pediatrics. 2012; 129: S68-S74
        • Effler P.V.
        • Chu C.
        • He H.
        • et al.
        Statewide school-located influenza vaccination program for children 5–13 years of age, Hawaii, USA.
        Emerg Infect Dis. 2010; 16: 244-250
        • King Jr., J.C.
        • Stoddard J.J.
        • Gaglani M.J.
        • et al.
        Effectiveness of school-based influenza vaccination.
        N Engl J Med. 2006; 355: 2523-2532
        • Piedra P.A.
        • Gaglani M.J.
        • Kozinetz C.A.
        • et al.
        Herd immunity in adults against influenza-related illnesses with use of the trivalent-live attenuated influenza vaccine (CAIV-T) in children.
        Vaccine. 2005; 23: 1540-1548
        • Monto A.S.
        • Davenport F.M.
        • Napier J.A.
        • Francis Jr., T.
        Modification of an outbreak of influenza in Tecumseh, Michigan by vaccination of schoolchildren.
        J Infect Dis. 1970; 122: 16-25
        • Asay G.R.
        • Cho B.H.
        • Lorick S.A.
        • et al.
        Coordination costs for school-located influenza vaccination clinics, Maine, 2009 H1N1 pandemic.
        J Sch Nurs. 2012; 28: 328-335
        • Cho B.H.
        • Asay G.R.
        • Lorick S.A.
        • et al.
        Costs of school-located influenza vaccination clinics in Maine during the 2009–2010 H1N1 pandemic.
        J Sch Nurs. 2012; 28: 336-343
      1. US Department of Education. Family Educational Rights and Privacy Act (FERPA). Available at: Accessed January 21, 2013.

        • Bergren M.D.
        HIPAA-FERPA revisited.
        J Sch Nurs. 2004; 20: 107-112
      2. Centers for Disease Control and Protection (CDC). CDC vaccine price list. July 18, 2011.

      3. Colorado Department of Health Care Financing and Policy. Provider bulletin, immunization. 2009.

      4. National Assembly on School-Based Health Care. School-based health center third-party billing: policies and systems. January 17, 2002. Available at: Accessed December 23, 2013.

      5. Smith VK. Opportunities to Use Medicaid in support of school-based health centers. June 1, 2002. Available at: Accessed December 23, 2013.

        • Yoo B.K.
        • Berry A.
        • Kasajima M.
        • Szilagyi P.G.
        Association between Medicaid reimbursement and child influenza vaccination rates.
        Pediatrics. 2010; 126: e998-e1010
        • Kansagra S.M.
        • McGinty M.D.
        • Morgenthau B.M.
        • et al.
        Cost comparison of 2 mass vaccination campaigns against influenza A H1N1 in New York City.
        Am J Public Health. 2012; 102: 1378-1383
        • Fontanesi J.
        • Jue-Leong S.
        Logistical and fiscal sustainability of a school-based, pharmacist-administered influenza vaccination program.
        J Am Pharm Assoc. 2012; 52: e74-e79
        • Glazner J.E.
        • Beaty B.L.
        • Pearson K.A.
        • Berman S.
        The cost of giving childhood vaccinations: differences among provider types.
        Pediatrics. 2004; 113: 1582-1587
        • Coleman M.S.
        • Lindley M.C.
        • Ekong J.
        • Rodewald L.
        Net financial gain or loss from vaccination in pediatric medical practices.
        Pediatrics. 2009; 124: S472-S491
      6. 111th Congress. Patient Protection and Affordable Care Act. HR 3590, 111–148.

      7. 111th Congress. Health Care and Education Reconciliation Act of 2010. HR 4872, 111–152.

      8. Centers for Medicare and Medicaid Services. Medicaid program. Payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children Program. November 6, 2012.

        • Institute of Medicine
        Primary Care and Public Health: Exploring Integration to Improve Population Health.
        National Academies Press, Washington, DC2012