Factors responsible for immunizations referrals to health departments in North Carolina

Despite the existence of Medicaid and other programs designed to eliminate cost as a barrier to immunization in physicians' offices, referrals to local health departments for immunizations are common. Many children leave their physicians' offices without receiving needed immunizations. To determine: 1) the frequency and determinants of immunization referrals to health departments in North Carolina, and 2) the factors associated with private physicians' decisions to immunize Medicaid children in their offices and participate in the state-funded vaccine replacement program. The 2537 pediatricians and family physicians licensed in North Carolina were surveyed by mail using a 23-item, self-administered questionnaire. Seventy-two percent of physicians responded; 93% referred at least some children to local health departments for immunizations. Concern regarding parents' ability to pay for immunizations was the most important reason for referral for 93% of respondents. Forty percent referred all or some of their Medicaid patients; excessive paperwork, inadequate reimbursement, and parental preferences were the most common reasons. Only 33% of physicians had participated in the state's vaccine replacement program. Family physicians, and physicians in solo or two-physician practices in rural counties, and in practices caring for a small number of children on Medicaid were most likely to refer children covered by Medicaid and not participate in the state's existing vaccine replacement program. Medicaid and North Carolina's vaccine replacement program are not preventing large numbers of immunization referrals to health departments. Future programs designed to increase the proportion of children immunized in physicians' offices will not succeed if more effective incentives for physician participation are not developed.