Doctors Incentivized by CDC to Increase Vaccination Coverage

doctor with medical form and patientSTORY HIGHLIGHTS

  • The CDC administers a program known as AFIX to push health care providers to raise coverage rates among children and adults with all federally recommended vaccines.
  • A centralized surveillance database known as Immunization Information Systems (IIS) is the cornerstone of this program.
  • IIS encourages competition among staff by providing incentives and rewards for those who increase the vaccination rate the most.

Many people have encountered going to their physician’s office or their child’s pediatrician’s office and being coerced into “getting up-to-date with their shots.” This is not a rare or random occurrence. There is a method and approach that federal health officials expect health care providers to enforce in order to ensure that vaccination coverage goals are met at the local level.

CDC’s AFIX Approach to Increasing Vaccination Coverage

In 1993, the U.S. Centers for Disease Control and Prevention (CDC) began a program for health care providers known as Assessment, Feedback, Incentive and eXchange (AFIX).1 The purpose of the program is to enlist health care providers to improve service delivery of federally recommended vaccines and increase vaccination coverage levels by identifying areas of low vaccine uptake and improving delivery practices.1 The following is a brief description of the four components of the AFIX program:

The assessment component is the first step to evaluating the health care provider’s immunization records for children up to the age of 18. The CDC executes the assessment phase.

The goal of this stage is to identify opportunities for improving vaccine coverage levels and reducing missed vaccination opportunities.2 The CDC defines a “missed opportunity” as a healthcare encounter in which a person is eligible to receive a federally recommended vaccine but does not receive the vaccine.”3

The CDC expects health care providers to enter all vaccine records into the Immunization Information Systems (IIS), which is the CDC’s main source of data for assessment of vaccine coverage levels in the U.S. IIS is a national electronic vaccine surveillance tool and its functionality continues to expand.

The CDC states:

Population-based IIS will be the cornerstone of the nation’s immunization system. Responsibility for IIS development rests with state and local communities, with assistance from federal and state agencies, and private partners. With the increased IIS functionality comes the ability to execute population-based Assessments, utilize a Geographic Information System (GIS), and provide real-time interface with other data systems. This functionality and interface can streamline the process for Assessment of immunization coverage2

In addition, the CDC website notes:

An IIS provides a single data source for all community immunization providers, enabling access to records of children receiving vaccinations at multiple providers. It provides a reliable immunization history for every enrolled child and can also produce accurate immunization records if needed for school or summer camp entry.3

The CDC also utilizes computer software known as Comprehensive Clinic Assessment Software Application (CoCASA) that…

provides detailed reports on the specific diagnosis of the problem, for example, whether children start their series on time, whether and when patients drop out of the system, and whether vaccines are given simultaneously. CoCASA can also help to raise awareness on issues such as record keeping and documentation and the need for reminder and recall systems.2

This indicates that a centralized national electronic medical/vaccine record keeping system is being operated by the CDC and that a patient’s medical records, including vaccination history, is now or will be readily available to all health care providers, hospitals, federal and state government agencies, schools, etc.  This has serious implications for medical privacy, exercise of medical informed consent rights and the potential for abuse of personal information by social service and law enforcement agencies, as well as doctors discriminating against children and adults who have not received every federally recommended vaccine.

After the assessment is completed, the feedback process begins. It involves informing vaccine providers and their staff, including frontline staff such as clerical staff and office managers, about observations and results from the assessment. The observations include quality improvement strategies, patient dropout rates, missed opportunities and what CDC officials consider to be the inappropriate use of contraindications.2

Once the feedback is provided to health care providers, the incentives component comes into play. It involves techniques and strategies aimed to encourage staff and clinics to improve their vaccine provider services with the ultimate purpose of increasing compliance with use of all federally recommended vaccines.4 The CDC states:

While most health care professionals are motivated by an intrinsic desire to improve health care, extrinsic rewards, or incentives, are often helpful. An incentive is something that incites or has a tendency to incite determination or action. Often times, incentive programs cannot only help providers move forward in achieving their immunization goals; they can also enhance performance over time.2

The incentives are categorized into informal and formal.4 Informal incentives are less costly and include letters of recommendation, free vaccination information materials, etc.

Formal incentives are more lucrative, complex and costly.2 These include grants, scholarships and promotions of clinics as “Immunization Champions”, etc.4 The organizations that sponsor these incentives include coalitions promoting mandatory vaccination, medical trade associations, managed care/HMOs and vaccine manufacturers,2 many of whom have potential conflicts of interest.

The last stage involves the exchange of information necessary to raise vaccine coverage levels.2 This stage goes hand in hand with other incentives. The CDC follows up with health care providers to share information on how their practice’s vaccine coverage status compares to state norms and other vaccine providers in their local area. Information is also exchanged on vaccine compliance strategies that have been successfully used by other providers.4

CDC’s Recommended Strategies for Reducing Missed Opportunities

According to the CDC, several studies have shown that eliminating missed opportunities has the potential to increase vaccination rates by 20 percent.4 There are a number of strategies that CDC encourages vaccine providers to use to avoid “missed opportunities” for vaccination, which include:

  • Reminder and recall messages to patients.4
  • Improving provider education on the principles of vaccination and vaccination scheduling.4
  • Abiding by standing orders. The CDC defines standing orders as protocols whereby non-physician immunization personnel may vaccinate clients without direct physician involvement at the time of the immunization. Standing orders are implemented in settings such as clinics, hospitals, and nursing homes.”4

It is important to understand the aggressive strategies that health care providers are being taught to use to increase use of all federally recommended vaccines. Regardless of what vaccination or other health care choices you make for yourself or your family, it is so important to take the time to become fully informed about all the risks involved and defend your right to make a voluntary decision. It is your basic human right.


1 Centers for Disease Control and Prevention. Overview of AFIXNational Center for Immunization and Respiratory Disease Dec. 10, 2014.
CDC. The Four Components of AFIXNational Center for Immunization and Respiratory Disease Dec. 10, 2014.
CDC. Immunization Strategies for Healthcare Practices and ProvidersNational Center for Immunization and Respiratory Diseases.
Assessment, Feedback, Incentives eXchange Program (AFIX) Policies and Procedures GuideU.S. Department of Health and Human Services