Intersectoral cooperation to increase HPV vaccine coverage: an innovative collaboration between Managed Care Organizations and state-level stakeholders

ABSTRACT

In order to reduce disparities in human papillomavirus (HPV) vaccine coverage, intersectoral approaches are needed to reach vulnerable populations, including Medicaid enrollees. This manuscript describes a collaboration between Medicaid Managed Care Organizations (MCOs), the American Cancer Society, and a state health department in a Midwestern state to address HPV vaccination. Qualitative interviews (n = 11) were conducted via telephone with key stakeholders from the three participating organizations using an interview guide designed to capture the process of developing the partnership and implementing the HPV-focused project. Interviews were transcribed and coded using thematic analysis. Interviewees described motivation to participate, including shared goals, and facilitators, like pooled resources. They cited barriers, such as time and legal challenges. Overall, interviewees reported that they believed this project is replicable. Conducting this project revealed the importance of shared vision, effective communication, and the complementary resources and experiences contributed by each organization. Valuable lessons were learned about reaching the Medicaid population and groundwork was laid for future efforts to serve vulnerable populations and reduce health disparities. This work has significant implications for other organizations seeking to partner with large nonprofits, state health departments, MCOs, or others, and the lessons learned from this project could be translated to other groups working to improve vaccination rates in their communities.

KEYWORDS:

• Managed Care Organizations
• intersectoral cooperation
• HPV vaccination
• cancer prevention
• Medicaid

Introduction

Managed Care Organizations (MCOs) are uniquely positioned to promote preventive care and contribute to efforts to improve population health, given that approximately 65 million Americans are enrolled in a Medicaid MCO.¹ Operating on a fixed-fee model, MCOs strive to support a healthier population requiring fewer health-care services. One example of an area in which collaborating with MCOs could lead to a significant impact on population health is the promotion of the human papillomavirus (HPV) vaccine.² HPV causes about 33,700 cancer cases each year in the United States although the HPV vaccine could prevent the majority of these cases.^3,4 However, HPV vaccine coverage in the US remains low compared to other adolescent vaccines. In 2017 when this study was conducted, 66% of the adolescents had initiated the two-dose HPV vaccine series and only 49% had completed the series.⁵

Table 1. Key barriers and facilitators of partnership.

Facilitators identified	Quotes	Barriers to success	Quotes
Identify a shared vision	“It’s a priority for us to work with health plans across the country” (Interview1_ACS) “For us, it was a great way to promote our message about [the] HPV vaccine and to reach a broad population” (Interview4_state health department_Imm) “We wanted to be a partner with other areas in Iowa to improve the health care of the state overall” (Interview8_MCO)	Timeline	“Work backwards from when you’d actually want to start any kind of intervention and give yourself a long [time]” (Interview1_ACS)
Utilize group resources and foster positive group dynamics	“If Iowa Department of Public Health hadn’t been at the table, I don’t know that we would have gotten a yes” (Interview1_ACS) “Just to have that kind of synergy and partnership overall was really unique” (Interview9_ACS)	Data sharing	“Our legal team really had to look at [the data sharing] agreement. There was some back and forth, there was some redlining, and that takes time” (Interview6_MCO) “Sometimes it was a little bit hard to get timely data from the MCOs” (Interview9_ACS)
Focus on unified messaging and effective communication	“The [partnership] really sent a message to providers across the state that we’re all prioritizing it. Just coming from us it wouldn’t have been nearly as effective” (Interview8_MCO) “Having everybody physically here, having us all get together and meet together at the start was really important to establish a connection” (Interview2_MCO)	Organizational tensions	“There was a lot of politics going around at the time” (Interview1_ACS) “[making sure we were] not stepping on any toes” (Interview3_state health department_BCC)

Common barriers to HPV vaccination include parental hesitancy,^6–8 inconsistent or low-quality provider recommendations,^9–11 and health service delivery challenges that result in missed opportunities to vaccinate.¹² In interviews with high-performing health insurance plans, commercial, and Medicaid plans, respondents reported common challenges to HPV vaccination, including vaccine safety concerns, stigma regarding the sexual transmission of HPV, and the difficulty of getting patients to attend multiple visits to complete the series.¹³ Nonetheless, various provider-, patient-, and system-focused interventions have successfully increased HPV vaccination rates.¹⁴ A systematic review found that physicians and clinics are common targets for intervention, with effective strategies including provider assessment and feedback, and utilization of reminder-recall systems.¹⁵ These interventions often focus on changes at the clinic level and do not involve other agents, like insurers, in the health-care system who focus on population health.

However, with an increasing emphasis on improving population health, public health practitioners and researchers are eager to form new collaborations that will improve their ability to reach underserved populations to address issues like HPV vaccination. Several factors contribute to this growing focus on population health that make it a relevant topic for all actors in the health-care field, including MCOs. Firstly, the Institute for Healthcare Improvement’s “Triple Aim” initiative identified three goals for health systems: improve population health, lower costs, and improve the experience of care.¹⁶ At the same time, the rising cost of health care has led many health plans to transition from the traditional fee-for-service model to fixed-fee or value-based care models.¹⁷ Additionally, research findings continually show the importance of social determinants of health, and the World Health Organization has led a push to implement policies and programs that address this aspect of population health.¹⁸ Finally, the Patient Protection and Affordable Care Act focused heavily on population health, with provisions to expand insurance coverage, improve quality of care, and focus on health outcomes through Accountable Care Organizations (ACOs).¹⁹ Health-care systems and other actors, such as ACOs and payors, including Medicaid and MCOs have embraced this focus on population health through preventive care. In this context, many actors working to increase HPV vaccination coverage are eager to collaborate with previously “non-traditional” implementers of interventions, specifically insurers and health plans.²⁰

Partnership description

We present an example of one such partnership that formed and was able to promote the HPV vaccine through evidence-based interventions (EBIs). The collaboration presented here developed from a relationship between the American Cancer Society (ACS) and the Department of Public Health (DPH) in Iowa and their desire to partner with Medicaid, the state’s second-largest health-care payor. The ACS and DPH representatives were in the early stages of planning a pilot cancer screening intervention with the Medicaid office when the governor privatized Medicaid services and brought in three MCOs through a competitive bidding process. Representatives from DPH and ACS met with each of the new MCOs to generate interest in developing partnerships between the MCOs, focusing on their shared interests in population health, the improvement of member experiences, and cost reduction.

At the partnership kickoff meeting, the group chose to focus on cancer screening and prevention, with their first project focused on increasing HPV vaccination rates. This goal aligned with MCO quality goals and provided an opportunity to improve the related Healthcare Effectiveness Data and Information Set (HEDIS) Immunizations for Adolescents measures.

After reviewing the available evidence on HPV vaccine promotion commonly used by health plans, the group chose two interventions: 1) supporting providers in recommending HPV vaccination,²¹ and 2) patient reminders for the HPV vaccination.²² Both of these interventions are considered evidence-based by the Guide to Community Preventive Services;²³ are recommended by the Centers for Disease Control and Prevention’s (CDC) Assessment, Feedback, Incentive, and eXchange (AFIX) quality improvement program;²⁴ and have been shown to increase vaccine coverage in a variety of settings.^25–27 First, the group mailed a packet to health-care providers in the 610 Vaccines for Children (VFC) clinics across the state that included a cover letter with information on HPV vaccination rates, tips for making a strong recommendation for HPV vaccination, and links to provider education materials available on the internet. The letter was developed by the partnership team and was co-branded with their organizational logos in addition to logos of state-level partners. The packet also contained posters for exam rooms, CDC materials for providers, and a description of the reminder postcard to be mailed to Medicaid members. Next, postcards were designed individually for each MCO with messages in English and Spanish and were mailed to the parents of all Medicaid-enrolled children ages 9–12 who were not up to date with their HPV vaccination. The Department of Public Health was responsible for compiling and mailing both the packets and postcards and funding for this project was provided by the department.

In our study, we examined the process of how these Medicaid MCOs worked together to implement EBIs to increase HPV vaccination coverage among their member populations. At least one study has evaluated the impact of an HPV vaccination intervention implemented through an MCO,²⁸ but we are not aware of any studies examining the implementation of interventions involving multiple MCOs or collaboration among MCOs to address HPV vaccination. To better understand how the group worked together, we conducted stakeholder interviews following this initial project (described above) to explore how the collaboration developed, identify facilitators and barriers, and formulate recommendations for future collaborative efforts with MCOs.

Methods

To begin, the qualitative research team and partnership team identified the initial stakeholders of the collaborative process. E-mail recruitment of this group resulted in telephone interviews with 11 individuals, conducted by two members of the research team. Interviews lasted between 20 and 45 min. The length varied as some participants had more involvement in the project and therefore more thorough answers to our questions. Interviewers utilized a guide that was designed to capture the process of developing the partnership and implementing the HPV-focused project described above. Question development, guided by the Consolidated Framework for Implementation Research,²⁹ focused on the initiation of the partnership, barriers and facilitators, lessons learned, and the replicability of this type of collaboration in other states. The study protocol was reviewed by an institutional review board and was not determined to be human subjects’ research.

Interviews were digitally recorded and transcribed by a third-party service. All three members of the qualitative research team read the transcripts and developed a codebook. The two members of the coding team coded the same two transcripts and conferred to establish reliability. After discussing and resolving coding discrepancies, the coders split the remaining transcripts between them. All team members discussed the coded transcripts to formulate results and conclusions.

Results

Research team members completed nine individual interviews and one joint interview with stakeholders of the original collaboration efforts. Interviewees represented the ACS (n = 2), three MCOs (n = 5), and two bureaus of the state public health department (Bureau of Immunization and Tuberculosis and Bureau of Chronic Disease Prevention and Management (n = 4)). Major themes that emerged in the coding of the interview transcripts are split into three broad categories: facilitators of partnership formation, challenges to success, and key lessons learned. Quotes are attributed to individuals based on the organization they are affiliated with: American Cancer Society (ACS), one of the three MCOs (MCOs), the state health department immunization program (Imm), or the state’s breast and cervical prevention program (BCC), which is part of the Bureau of Chronic Disease Prevention and Management.

Facilitators of partnership formation

Identify a shared vision

Participating organizations and individuals shared several motivators for joining this project. Representatives from all organizations expressed a desire to “reach large populations” (Interview1_ACS) beyond their usual scope. All respondents reported wanting better ways to provide services to the Medicaid population, because as one individual noted “we know that they have a lot more barriers and could use more support to access screening services” (Interview9_ACS).

Another motivator shared by all was the project’s alignment with their organizations’ mission or current organizational (and/or individual) goals. One ACS participant stated, “It’s a priority for us to work with health plans across the country” (Interview1_ACS), adding that the project also fits their own professional goals. MCO participants emphasized a commitment to the health of their members, stating the “overall mission and goal is to improve the health of Iowa’s residents” (Interview8_MCO). Another major facilitator was the project’s focus on HPV vaccination, as this was a high priority for all those involved. The focus on HPV vaccine promotion allowed the partners to address “the gap between how many cancers we could be preventing and how low the vaccination rates are” (Interview1_ACS). Health department participants also emphasized mission alignment, with the two participants from the department’s Immunization Bureau specifically interested in the focus on vaccination:

For us, it was a great way to promote our message about [the] HPV vaccine and to reach a broad population not only through the insurance companies and their nurse clinicians but their patient population. And then to reach out to all health care providers in [state]. (Interview4_state health department_Imm)

In reference to the collaborative process, all partners expressed a desire to forge new connections and strengthen existing relationships. While the ACS and the DPH had previously collaborated, the MCOs and their staff were new to the state and participants declared their desire to be part of a collaborative effort. One MCO participant stated that “from an organizational perspective, we wanted to be a partner with other areas in Iowa to improve the health care of the state overall” (Interview8_MCO). This sentiment was echoed by an ACS participant who said, “the larger goal was population health through partnership” (Interview1_ACS). Importantly, each organization agreed that the partnerships were formed with a long-term goal of continuing to collaborate as relevant opportunities arise. This expectation was expressed by a DPH participant who said, “I think the best part about this is, regardless of the funding opportunities, that we’ve built these relationships and we can continue to work on these activities together, regardless of if there’s dollars available” (Interview7_state health department_Imm). Finally, MCO participants emphasized that they had wanted to work with the other MCOs in the state, referencing the value of “coming together to make a big effort that would really grab the attention of not just our members, but of providers” (Interview6_MCO).

Utilize group resources and foster positive group dynamics

Cooperation emerged as a primary facilitator of the project’s implementation. All organizations agreed that the project could not have been accomplished alone, and that the unique contribution of skills and resources from each organization was crucial. An ACS participant appreciated the increased influence the organization gained through partnering, pointing out that in addition to supplying financial resources, the state health department brought “some weight to our conversation with the Iowa Medicaid and if Iowa Department of Public Health hadn’t been at the table, I don’t know that we would have gotten a yes” (Interview1_ACS).

Interview respondents reiterated the importance of the positive group dynamics fostered by the partnerships. An ACS participant stated that “just to have that kind of synergy and partnership overall was actually unique” (Interview9_ACS). From a more practical standpoint, a DPH participant noted the importance of “a certain amount of resources, whether that be the time [or] materials” (Interview7_state health department_Imm). An MCO participant was more specific about the partnership’s valuable combination of resources:

American Cancer Society and [Iowa Department of Public Health] did a lot with financial resources. They also facilitated the meetings and provided the meeting sites. [The state health department] provided messaging and materials that they had used in the past, so we didn’t have to recreate that. They had resources available we were able to utilize. The other MCOs like ourselves, we created the creative process and the developing process, the mailing list and the reporting. (Interview10_MCO)

Focus on unified messaging and effective communication

Joining together to provide a unified message was perceived to have a significant impact. As one MCO participant summarized: “[The partnership] really sent a message to providers across the state, that we’re all prioritizing this. Just coming from us it wouldn’t have been nearly as effective” (Interview8_MCO).

An overall commitment to communication was also identified as fundamental for success. One participant recalled, “In the beginning, we really established that we wanted to stay connected” (Interview6_MCO) and noted the importance of biweekly conference calls that provided “a set amount of time to connect and really discuss any barriers that we were having.” In addition to the biweekly calls, the group took the time to occasionally meet in person, which one participant considered to have set the tone for the project: “Having everybody physically here, having us all get together and meet together at the start was really important to establish a connection and to get everybody invested” (Interview2_MCO). Additionally, the MCO quality directors participated in weekly calls with the “sole objective for those conversations [being how to] work together to better serve our members and improve our plan performance” (Interview2_MCO). Table 1 presents a summary of key barriers and facilitators.

Barriers to project implementation

One challenge encountered during project implementation was the disproportionate amount of time required to launch the activities. Partners agreed on the importance of dedicating adequate time for planning, with advice from one stakeholder to “work backwards from when you’d actually want to start any kind of intervention and give yourself a long [time], like 9 to 12 months if you can” (Interview1_ACS).

A key factor in the unexpected length of the planning timeline was the coordination needed for sharing information; one ACS participant specified that “sometimes it was a little bit hard to get timely data from the MCOs” (Interview9_ACS). Second, complex legal issues were encountered related to data sharing. In order to complete the mailing to members, the MCOs had to share names and addresses of non-compliant members with the Department of Public Health, which proved to be an onerous and frustrating process. As an MCO participant observed, “The biggest challenge that I think we ran into was actually a data sharing agreement,” adding “Our legal team really had to look at that agreement. There was back and forth, there was some redlining, and that takes time. I think that we didn’t anticipate how much time that would take” (Interview6_MCO). A DPH interviewee called data sharing “our biggest concern” (Interview4_state health department_Imm), indicating that the data-sharing agreement proved to be a complicated, time-consuming issue for all three organizations.

Finally, participants from the ACS and state health department alluded to potential organizational tensions, both external and internal, during project development. “There was a lot of politics going around at the time” (Interview1_ACS), as one ACS participant referenced the Medicaid privatization. Internal politics also required navigation, described by one state health department participant as, “not stepping on any toes” (Interview3_state health department_BCC) of those involved in similar work. The same individual expressed a concern that those with similar projects were “in the know about what we were doing,” while at the same time asking, “How big do you make this collaboration group before people start to lose interest, before it gets too big?” (Interview3_state health department_BCC).

Lessons learned and replicability

Participants generally agreed that it would be feasible to replicate this project in other states with certain prerequisites, the most fundamental being a strong willingness to cooperate. Along those lines, an MCO participant wondered if “there [is] a little more competition” (Interview8_MCO) in other states with more established MCO systems that could make such collaboration more difficult. Similarly, one DPH participant noted that while the project is replicable, Iowa may have some unique qualities that facilitated the collaboration:

I do know also that from hearing from other states, [Immunization Bureau] do not have as good of a relationship with these organizations. I know they don’t all work as well with ACS, I know they don’t all have a strong as cancer consortium as we do. Yeah, I don’t know if they’ve been in contact with their health systems to do these types of interventions. So I think it could be done but I think we [have] some unique qualities here in [state] where we have built those relationships. (Interview_state health department_Imm)

Regarding the potential for sustainability, participants from all organizations agreed that their collaborative project had created new partnerships, strengthened existing ones, and left them well positioned to collaborate in the future. As one MCO participant said, “Now we know, okay, the next thing that comes through the door we can collaborate together and we can accomplish it” (Interview8_MCO). Table 1 presents a summary of the key facilitators and barriers we identified.

Discussion

The combined activity of MCOs, the ACS, and the Iowa public health department demonstrates the feasibility, accomplishments, and benefits of partnerships between diverse organizations. Their success in sustaining this partnership offers important lessons for other states or organizations looking to partner with MCOs to promote population health and improve health outcomes of Medicaid enrollees, either to address HPV or other vaccination challenges. Additionally, our findings add to the growing literature attempting to better understand and evaluate collaborative partnerships in health care.^30,31 Our study sought to explore the determinants of successful collaboration between non-traditional partners to address HPV vaccination. While our participants reflected on their collaborative HPV project, we believe the lessons that they learned through this process would translate to other vaccine promotion efforts and could be replicated by similar groups.

Participants identified several key factors that facilitated the success of this project that included shared vision and recognition of each organizations’ contributed resources. These findings echo other studies assessing similar questions about the determinants of successful partnerships, which also highlight the importance of a shared vision and utilizing all available resources.^32,33 In this case, the shared vision that the organizations began with not only enabled them to work on this HPV project but because of each organization’s commitment to population preventive health overall, also allowed the group to expand to work on other efforts, through which they can use the same resources. Taking the time early in the partnership to identify shared interests beyond the immediate project may be beneficial for sustainability. In this case, because of the group’s dedication to cancer prevention and screening, but more broadly on improving population health, they have been able to find common ground and continue their partnership. The group has successfully completed subsequent projects on HPV vaccination, breast, and cervical cancer screening, and is currently discussing the possibility of addressing men’s health issues or sexual health screenings.

While in agreement on the feasibility of replicating and sustaining similar partnerships in other states, interviewees shared important lessons for fostering collaborations specifically with MCOs that may be relevant for other organizations attempting to partner with payors. This included the need to allot sufficient time for potentially complicated negotiations over data sharing and being careful not to overstep boundaries. States with multiple established MCOs may face more of these logistical and political challenges, as in many cases these organizations are competitive in nature. However, most of the research to understand the relationships between these types of organizations focuses primarily on the financial and quality impact of competition.³⁴ Therefore, this is an area that needs further work to understand how to incentivize collaboration in an environment that may be competitive by design.

Ultimately, our results can be summarized in three suggestions for partnership formation to address population health issues: identify a shared interest or vision, make a plan for regular and effective communication, and utilize the unique resources and experiences contributed by each organization. In this case, all organizations involved benefitted from the resources and expertise supplied by the others, whether it was time, member mailing lists, or funding. Interviewees agreed that the pooling of resources allowed every organization to effectively reach a broader population than would have been possible if each had acted alone, and some even stated that the project would not have been possible if they were to conduct it on their own. Moreover, this joint effort allowed them to spread a unified message across the state to both Medicaid members and providers about priorities for HPV vaccination. Having all of the MCOs be able to share the same message being spread by the state health department and the ACS demonstrated unity and a strong commitment across the state to HPV vaccine promotion. For individuals or organizations trying to form similar collaborations to address vaccination, or other issues, these suggestions may contribute to their success.

Strengths and limitations

We believe this study adds to the important conversation around how to partner with different organizations to address population health issues. While we focused on HPV vaccination, we believe the lessons learned from this collaboration would translate to groups hoping to work on collaborative projects related to other adolescent or adult vaccinations and beyond. One limitation is related to the qualitative nature of our study. While we believe our results offer important lessons for other groups, these findings are not generalizable beyond this specific context.

Conclusions

Forming this partnership established new relationships and strengthened existing ones among all participating organizations. Their continued association reflects the successful achievement of their goal to lay the groundwork for sustainable relationships that expand the reach of their cancer prevention efforts for the Medicaid population. In fact, although some organizational leadership and participation have shifted since the pilot project, the partnership is still actively pursuing projects, and several new members have joined. These results highlight the importance of seeking out unique partners, including payors, to involve in projects aimed at improving population health, like vaccination. Other states or entities exploring ways to strengthen existing partnerships or reach out to new potential collaborators to increase vaccine rates, or address other public health challenges, can learn from this collaborative effort.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Acknowledgments

The authors wish to thank the American Cancer Society, State Department of Health, and Medicaid Managed Care Organization staff who spearheaded this collaboration.

Additional information

Funding

This work was supported by the Centers for Disease Control and Prevention under Cooperative Agreement Number NH23IP000953.