Financial incentives for childhood immunisation — a unique but changing Australian initiative

The Immunise Australia: Seven Point Plan1 (Box 1) was launched in 1997 to increase childhood immunisation coverage from its then level of 53%.2 A range of financial incentives for general practice and parents was one component, unique among high-income countries when it commenced in 1998.3 Incentives targeted at general practice remained largely unchanged for over a decade, but those targeted at parents have been modified several times. The 2012 Federal Budget heralded significant reforms to financial incentives for immunisation, and there has been discussion about their possible impact. Here we document the history and consider the potential impact of changes to financial incentives for immunisation targeting providers and parents in Australia.

The original General Practice Immunisation Incentive scheme offered two financial incentives for general practices that registered for it: the Service Incentive Payment and the Outcomes Bonus Payment. Since 1996, the Australian Childhood Immunisation Register (ACIR) has offered general practitioners a notification payment for reporting vaccines administered to children under 7 years of age. The National Human Papillomavirus (HPV) Vaccination Program Register introduced the same notification payment for the time-limited community catch-up program. Although not strictly an incentive, the Medicare Benefits Schedule has included several item numbers directly supporting immunisation service provision (Box 2).

The Service Incentive Payment ceased in 2008 and in May 2013 the Outcomes Bonus Payment will end (Box 2). The latter will mean a general practice with 600 whole-patient equivalents will lose around $2100 per quarter, while a smaller practice of 30 whole-patient equivalents will lose around $100 per quarter. These changes align general practice and state and local government immunisation providers (eg, community health) as, although eligible for the ACIR notification payment, these providers have never been eligible for the General Practice Immunisation Incentive scheme. The ACIR notification payment continues at $6, the same amount offered when it was first introduced.

Under the Seven Point Plan, immunisation was linked to the existing Maternity Immunisation Allowance (MIA) and childcare-related payments (Box 2). In 2009, the MIA was split into two payments: continuing financial incentives for vaccines due by 12 months of age and introducing a financial incentive for vaccines due at 4 years of age, when coverage and timeliness were lowest. From July 2012, the MIA was discontinued; instead, immunisation status became linked to the existing means-tested Family Tax Benefit (FTB) Part A supplement for each child at ages 1, 2 and 5 years.4 To be eligible for this offset at these three age milestones, a child must be recorded as fully immunised. From July 2013, the fully immunised criteria will expand from nine to 12 antigens (Box 2). Immunisation status is also reviewed by a health professional during a health check offered from 3 years of age that meets the criteria for a Healthy Start for School check (including but not limited to the Healthy Kids Check). Documented completion of a Healthy Start for School check is linked to receipt of the FTB Part A supplement for 4-year-old children. In line with the tax system, parents will have two financial years to fulfil the immunisation requirements for the FTB Part A supplement, a grace period greater than was allowed for the MIA.4 Parents who do not want or cannot have their children immunised will still need to apply for an exemption in order to receive the family tax and childcare benefits for which they are eligible.

Since the Seven Point Plan was introduced, national childhood immunisation coverage has risen to over 90%.5 After the removal of the Service Incentive Payment, coverage remained stable,5 although there is concern that it will fall following the cessation of the Outcomes Bonus Payment.6 With the addition of three more antigens to the “fully immunised” criteria, it is possible that coverage will appear lower; however, it will be difficult to disentangle the relative impact of the various changes to incentives and the “fully immunised” criteria.

Legislated parental incentives for childhood immunisation have been broadly accepted among Australian parents and have had a positive impact on uptake and timeliness.5,7 These incentives are likely to have been sufficient to motivate parents to immunise their children and to prompt their provider to notify the ACIR in a timely manner.5 Based on data from the Australian Bureau of Statistics, of the 2.05 million recorded families in Australia in 2011, around 73% appear eligible for the FTB Part A supplement.8,9 For many of these families, there will now be more dollars at stake for ensuring that their children are fully immunised. For the minority of higher income families who are not eligible for this and/or the childcare-related benefits, there will no longer be any financial incentive for immunisation. Other families will be eligible for some or all of these incentives in part but, due to means-testing of these payments, the dollar value may not be as great as that previously provided by the MIA. The larger incentive could increase the 1.5% currently registered conscientious objectors,5 because parents who previously did not attempt to claim the MIA but are eligible for the FTB Part A supplement may now be more motivated to register their objection.

The Outcomes Bonus Payment was intended to supplement some of the infrastructure and administration costs for vaccination services provided by general practice. It is possible that the remaining ACIR notification payment and the non-immunisation-specific Practice Nurse Incentive Program may not supplement this to the same extent. However, demand from parents, accreditation requirements, established reporting habits and public health altruism are likely to continue to drive the provision of childhood immunisation and ACIR reporting at the provider level. A reduction in bulk-billing for childhood immunisation is also unlikely, as the Medicare Benefits Schedule item incentive to bulk-bill those under 16 years of age remains, and there is no current evidence of a decline in bulk-billing rates nationally.10

The impact of the financial incentives for childhood immunisation introduced in Australia from 1998 has been challenging to evaluate, given the many other changes in the immunisation landscape1 over this period. Retrospective evaluations and ecological evidence indicate that the childhood immunisation incentives introduced in Australia are likely to have made a significant contribution to increasing childhood immunisation coverage to over 90%.5,7 However, the relative impact of incentives for parents and for GPs is likely to be difficult to disentangle.