September 27, 2019

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1713-P
P.O. Box 8010,
Baltimore, MD 21244-8010

RE: CMS-1713-P Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program

To Whom It May Concern:

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Medicare Program End Stage Renal Disease Prospective Payment System (ESRD PPS) and Quality Incentive Program proposed rule. AVAC remains deeply concerned that the ESRD PPS no longer includes immunization quality measures for health care professionals or the patients they serve. Our coalition strongly encourages CMS to consider the inclusion of the Composite ESRD Immunization measure for ACIP-recommended vaccines (influenza, pneumococcal and hepatitis B) under the ESRD Quality Incentive Program (ESRD QIP) in the final rule. This new composite measure would promote higher quality and more efficient health care for vulnerable ESRD patients who are at increased risk of vaccine preventable illness.

AVAC consists of 55 organizational leaders in health and public health that are committed to addressing the range of barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our priorities and objectives are driven by a consensus process with the goal of enabling the range of stakeholders to have a voice in the effort to improve access and utilization of adult immunizations.

Despite the well-known benefits of immunizations, more than 50,000 adults die from vaccine-preventable diseases while adult coverage lag behind Healthy People 2020 targets for most commonly recommended vaccines: influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, and HPV.5,6 One of our key coalition priorities is to advocate for federal benchmarks and quality measures to encourage improved tracking and reporting of immunization status that will result in increased adult immunization rates.

In 2016, AVAC released a White Paper outlining the value and imperative of quality measures for adult vaccines. The report highlights the role of vaccine quality measures in preventing illness and death, reducing caregiving demands, avoiding unnecessary healthcare spending, and setting the foundation for healthy aging. Quality measurement programs through Medicare play a critical role in promoting improved quality and encouraging adherence to and consistent utilization of recommended adult vaccines.

The Department of Health and Human Services (HHS) recognizes that immunization is an important tool to keep people healthy and reduce avoidable health care costs. In its Strategic Plan FY 2018 –2022, HHS acknowledges that “infectious diseases are a major health and economic burden for the United States.” Additionally, strategic objective 2.1 makes a commitment to “support access to preventive services including immunizations and screenings, especially for high-risk, high-need populations.” Unfortunately, access to vaccines is not equal across a person’s lifespan.

Composite ESRD Vaccination Measure
The HHS National Vaccine Program Office (NVPO) and the Centers for Disease Control and Prevention (CDC) in collaboration with the National Adult Immunization and Influenza Summit Quality Working group spearheaded the development and testing of a new composite measure for end-stage renal disease patients covering influenza, pneumococcal and hepatitis B vaccines. A review of CMS fee-for-service claims data warrants the use of such a measure as current vaccination rates for the ESRD population fall well below recommended targets.

Research has shown that kidney care centers with vaccination protocols have demonstrated reduced infection rates and resulted in decreased morbidity and mortality. Vaccines, including hepatitis B and pneumococcal conjugate and pneumococcal polysaccharide, are specifically recommended for dialysis or CKD patients. However, like with other adult populations, vaccines are underutilized in CKD patients, who could benefit greatly from improved access to immunization services.

A composite measure for ACIP-recommended vaccines for ESRD patients would be of great benefit to the ESRD QIP now and in the future. The ESRD QIP presents an important opportunity to promote higher quality and more efficient health care for Medicare beneficiaries that preserves health and avoids unnecessary health expenditures due to vaccine preventable illness. AVAC strongly believes the ESRD QIP should include a focused, concerted effort to improve access and utilization of adult immunizations as a means of improving the overall health of patients living with kidney disease. An ESRD composite measure would provide a sound, reliable and comprehensive means to assesses the receipt of routine adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP).

We look forward to working with CMS to ensure meaningful measures that reflect priority health care services, such as immunization, that will streamline and reduce the reporting burden on providers, provide an accurate representation of ESRD facility performance in the least burdensome manner possible and provide meaningful data to the Medicare program on access to this important preventive service.

We appreciate this opportunity to share our perspective on this proposed rule. Please contact an AVAC Coalition Manager at (202) 540-1070 or if you wish to further discuss our comments. To learn more about the work of AVAC visit


Alliance for Aging Research
Asian & Pacific Islander American Health Forum (APIAHF)
Association of Immunization Managers
Biotechnology Innovation Organization
Families Fighting Flu
Immunization Action Coalition (IAC)
National Association of County and City Health Officials (NACCHO)
National Black Nurses Association
The Gerontological Society of America
Trust for America’s Health