Building Better Metrics:  Immunizations and Asking the Right Question(s)

As policy experts cling to pay-for-performance (P4P) as an indicator of healthcare quality and shy away from fee-for-service, childhood immunization rates are being utilized as a benchmark.  At first glance, vaccinating children on time seems like a reasonable method to gauge how well a primary care physician does their job.  Unfortunately, the parental vaccine hesitancy trend is gaining in popularity.  Studies have shown when pediatricians are specifically trained to counsel parents on the value of immunizations, hesitancy does not change statistically

Washington State Law allows vaccine exemptions on the basis of religious, philosophical, or personal reasons; therefore, immunizations rates are considerably lower (85%) compared to states where exemptions rules are tighter.  Immunization rates are directly proportional to the narrow scope of state vaccine exemptions laws.  Immunization rates are used to rate the primary care physician despite the fact we have little influence on the outcome according to scientific studies.  Physicians practicing in states with a broad vaccine exemption laws is left with two choices:  refuse to see children who are not immunized in accordance with the CDC recommendations or accept low quality ratings when caring for children whose parents with beliefs that may differ from our own.   

The more willing a physician is to care for those with differing philosophical, religious, and cultural beliefs, the more CMS metrics will discriminate against our open-hearted approach.  Reflecting upon my medical school admissions interview, my open heart and mind are some of the reasons for entering medicine in the first place.  As I contemplated my tumbling quality indicators by continuing to see children regardless of immunization status, I stumbled upon some ICD-10 code gems: 

  • Z28.0  Immunization not carried out because of contraindication
  • Z28.01 – Immunization not carried out because of acute illness of patient
  • Z28.02 – Immunization not carried out because of chronic illness or condition of patient
  • Z28.03 – Immunization not carried out because of immune compromised state of patient
  • Z28.04 – Immunization not carried out because of patient allergy to vaccine or component
  • Z28.09 – Immunization not carried out because of other contraindication
  • Z28.1     Immunization not carried out because of patient decision for reasons of belief or group pressure
  • Z28.2  – Immunization not carried out because of patient decision for other and unspecified reason
  • Z28.20 – Immunization not carried out because of patient decision for unspecified reason
  • Z28.21 Immunization not carried out because of patient refusal
  • Z28.29 – Immunization not carried out because of patient decision for other reason
  • Z28.8  – Immunization not carried out for other reason
  • Z28.81 – Immunization not carried out due to patient having had the disease
  • Z28.82 – Immunization not carried out because of caregiver refusal
  • Z28.89 – Immunization not carried out for other reason
  • Z28.9 – Immunization not carried out for unspecified reason

Surprisingly, ICD-10 and the advanced coding technology might have had some unanticipated benefits.    If a physician uses vaccine refusal codes appropriately, the patient in question should be removed from the denominator being used to calculate immunization rate for a given clinic or physician. 

This allows immunization rates to reflect “quality” while accounting for factors outside the control of the primary care physician.  Vaccine exemption laws must be considered confounding variables when using immunization rates as a quality metric; eliminating confounding variables purifies the data set.   This is a simple concept, so why are metrics being collected by CMS not controlling for caregiver refusal when it is mandated by law?  Accuracy is the point of collecting data in the first place, right?  If you believe CMS is interested in accuracy, then I have a bridge somewhere to sell you on the Olympic Peninsula.

ICD-10 codes already allow for regional specificity; a physician in Washington State has codes when a patient is pecked by a chicken (W61.33) or bitten by a cow (W55.21); there is even a code when a one is struck by an Orca Whale (W56.11), an event more likely to occur in Washington than Idaho.  If we can code for injuries sustained when our water skis catch on fire (W91.07) after a civilian boat collided with a military watercraft (V94.810) while waterskiing on the Puget Sound near the Naval Undersea Warfare Center Keyport, then we certainly should be capable of controlling for confounders which do not reflect the “quality” of care a physician provides.   

Claude Levi-Strauss, once said, “The scientific mind does not so much provide the right answers as ask the right questions.”  Immunization rates are clearly NOT an accurate quality indicator.  Maybe it is time for policy experts and physicians to question what constitutes the provision of high-quality health care in the first place.  Only then, can this country move in the right direction. 

14 replies »

  1. My favorite question EVER is “Aren’t there any doctors involved in developing these rules?” Why NO Barry, we are not involved in any way, shape or form. Do you think anyone over at CMS has ever given an vaccination talk to a hesitant parent? Of course not. My larger point is if CMS cannot understand this very simple problem (which has been presented to them many times) then why do they have control of the quality metrics for the entire nation? It is some of the reason our healthcare system remains a mess.

  2. ” they want to hamstring physicians into paying out of pocket to stay in practice.”

    Yes, and there’s always Drexit…

  3. Of course. The more force one applies, the more counter force seems to materialize. The unfortunate consequence is measles, rubella, pertussis and mumps are returning to the forefront

  4. I absolutely agree. Basic health care screenings and such should absolutely be administered on a large scale as a part of our public health system

  5. Yes EHRs were designed to monitor…docs and patients. You wait until health information is available for purchase someday.

  6. I agree it has a lot to do with trust. That is actually the title of one of my very first blog posts. However, one can artificially drive up their numbers my altering their panel and accepting only patients who immunize. Is that physician really more trustworthy?

  7. The answer to your question is it doesn’t jibe. Basically, MOC is a cash cow for the ABMS organizations. They don’t care about quality, they want to hamstring physicians into paying out of pocket to stay in practice.

  8. Has anyone noticed that the more beligerant and authoritative the CDC/HHS becomes, the more momentum the anti vaccine movement picks up?

  9. I think childhood immunizations should be removed from the practice of medicine and placed under the authority of local health departments and law enforcement. We can’t possibly be intellectually honest, ethical, patient centered and also carry out the Government’s public health agenda at the same time.

  10. Such a shame….appears to be the degradation of an honored profession. N of 1, but I can’t stand my doc glued to the computer screen pestering me to have this or that done, apparently fearful of a bad rating. Seems EHR’s were mainly just to monitor docs (and patients)….what a waste.

  11. People who refuse to be vaccinated due to religious, cultural or philosophical objections should absolutely be excluded from the denominator of the metric used to measure physician quality. It’s simple common sense. Aren’t there any doctors involved in developing these rules?

    Policymakers can still look at the gross numbers of vaccinated people as a percentage of the total population and review the codes to break down the reasons why some people choose to refuse vaccination. There are some complex problems in healthcare. This is NOT one of them, at least in my opinion.

  12. Any discussion about immunization practices ultimately should focus on TRUST. The CDC compiles an estimate of immunization levels state by state. I have always viewed it as an indirect measure of the level of TRUST within the State’s citizens for their Primary Healthcare. Similarly, this might also apply to a state’s Maternal Mortality Ratio. Amazingly, after a 10 year absence, a State by State data-set was finally published last October in OB & GYN. It is grim.
    The daily experience of immunization practices is frustrating to manage given the distractions that produce missed opportunities, all aggravated by social adversities for which we have little over-all control ( eg, citizen mobility). It seems that Primary Healthcare will continue to be awash amidst the winds of change within each community, especially since we lack any means to assure its equitable availability for each citizen, community by community.

  13. The government, once again has opposing views on how patients should be treated. I am in the process of doing my required MoC for Family Medicine. As such, I am doing the requisite module on Cultural Competency (developed by HHS). Going through the course, it describes how doctors should embrace and respect the cultural values of many different ethnicities, including use of prayer, herbal remedies, shamanic healers, etc. OK, all well and good, but my question is, how does this jibe with both the medical-legal aspects of patient care, and more importantly, the “quality measures” ? I see a huge discrepancy between trying to respect and compromise with someone’s cultural beliefs about their medical care and following rigorous guidelines required by the quality measures.