AVAC Letter on Fiscal Year 2023 Appropriations

April 6, 2022 

 

The Honorable Rosa DeLauro
Chair
House Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies
Washington, DC 20515

The Honorable Tom Cole
Ranking Member
House Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies
Washington, DC 20515

The Honorable Patty Murray
Chair
Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies
Washington, DC 20510

The Honorable Roy Blunt
Ranking Member
Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies
Washington, DC 20510

Dear Chairwomen DeLauro and Murray and Ranking Members Cole and Blunt: 

As members of the Adult Vaccine Access Coalition (AVAC), we write to ask for full funding of immunization-related activities at the Department of Health and Human Services as part of the fiscal year (FY) 2023 Labor, Health and Human Services (LHHS), and Education Appropriations bill.

The COVID-19 pandemic put a tremendous strain on our chronically underfunded public health infrastructure and exposed important weaknesses that simply must be addressed. It has also reminded us of the importance of health promotion and disease prevention efforts. Vaccines help mitigate disease, prevent severe illness, and reduce hospitalizations, morbidity, and mortality. 

Over the course of the pandemic, we have seen a precipitous drop in immunization rates across all ages, young and old. Before the pandemic, adult immunization rates were already below national targets, especially in underserved communities, where the risk of poor outcomes was highest. The pandemic only exacerbated these alarming trends.  A recent analysis conducted by Avalere Health revealed that adolescents and adults may have missed an estimated 37.1 million doses of recommended vaccines between December 2020 and July 2021 compared to the same time in 2019.1    

Routine immunization is core to public health, preventing billions of dollars in medical costs and lost productivity. Our nation cannot allow expanded vaccine access to erode as the public health emergency winds down. It is vital that our nation leverage the substantial progress and investments that have been made from the COVID-19 vaccination program. The opportunity we have before us today, is not just to return life course immunizations to pre-pandemic levels, but to build upon and exceed them.  

It is critical that the LHHS appropriations bill includes sustainable funding for immunization efforts, including long-term investments in immunization infrastructure, including immunization information systems, vaccine confidence campaigns, and support for health care providers. Immunizations are a sound investment because they are a highly cost-effective form of preventive medicine that help save lives by protecting the health and wellbeing of individuals and families in communities nationwide.  

AVAC strongly supports the President’s FY2023 budget as it proposes a substantial increase in the CDC immunization program that provides foundational support for state and local health department activities. The proposal supports not only COVID-19 vaccination, continue research related to long COVID-19 conditions and, support influenza programming, and enhance support in the human papilloma virus (HPV) vaccination efforts in alignment with the Administration’s Cancer Moonshot Initiative priorities. Since 2020, Congress made substantial emergency investments to ensure that all eligible individuals had access to the COVID-19 vaccine. It is imperative that Congress sustain these important investments beyond the immediate threats of the pandemic to help transition our Nation to a sustainable program to support not only COVID-19 vaccination but also supporting recovery of routine childhood, adolescent and adult vaccination that have been missed. The President’s FY2023 budget also proposes an immunization program that is focused on the long-neglected needs of the adult population. This program would go a long way toward addressing access, education and outreach and continuing to encourage more providers across the health care continuum to make immunization a routine part of their clinical workflow for all adult patients. 

We ask the Committee to strongly support: 

$1.13 billion to fully fund the National Immunization Program at the Centers for Disease Control and Prevention (CDC)’s National Center for Immunization and Respiratory Diseases (NCIRD)(+$400m). The immunization program at CDC provides funding to state and local health departments to carry out a variety of activities vital to the prevention, detection, and mitigation of vaccine-preventable conditions. These essential grants are utilized not only for the purchase of vaccines, but also support a number of other important activities, including: surveillance, safety and effectiveness studies, education and outreach, implementation of evidence-based community interventions to increase immunization coverage among underserved and high-risk populations, and vaccine-preventable disease outbreak response. The resources provided under the immunization program are vital to communities across the country, many of whom rely solely on these funds to support their immunization activities.   

Establishment of the Vaccines for Adults Program (VFA).  We wish to express support for the newly proposed Vaccines for Adults Program, which seeks to provide uninsured adults with access to all vaccines recommended by the Advisory Committee on Immunization Practices at no cost. This new program would create a life course approach to immunization, by complementing the longstanding success of the Vaccines for Children Program (VFC). To ensure all Americans have access to recommended vaccines, we continue to support expansion of existing coverage programming, including the elimination of Financial Barriers in Medicare Part D and Medicaid. 

$251 million for Influenza Planning and Response at CDC’s NCIRD (+$50m). CDC’s Influenza Planning and Response programs help to protect the United States from seasonal influenza and pandemic influenza. Each winter, influenza causes millions of illnesses and hundreds of thousands of hospitalizations. Providing $241 million for the program will ensure CDC has the resources necessary to address the continual threats posed by seasonal and pandemic influenza. 

$140 million for CDC’s Division of Viral Hepatitis (+$94.5m). The National Viral Hepatitis Strategic Plan has for the elimination of hepatitis A, B, and C as public health threats in the United States. HAV and HBV have a safe and highly effective vaccine that can prevent infection. In 2021 Advisory Committee Immunization Practices (ACIP) made a paradigm shift from a risk-based recommendation to a routine recommendation that all adults between 19 and 59 be vaccinated for hepatitis B. Currently, only 25% of adults are vaccinated for HBV.  Chronic HBV requires life-long medical care, as there is no cure. With this new recommendation there is an opportunity to take us closer to the elimination of hepatitis B but will need improved funding to implement that important routine recommendation.  Providing $140 million will be essential to expand adoption of recommendations for HBV and HCV testing, HBV vaccination, and linkage to care. 

$12.7 million for the Office of Infectious Disease and HIV/AIDS Policy (OIDP) (+$5m). OIDP plays a vital role in directing and implementing HHS and federal government-wide policies, programs, and activities related to vaccines and immunization. This portfolio includes providing policy leadership, outreach and coordination on vaccine and immunization-related activities among federal agencies and non-federal stakeholders, implementation of Vaccines National Strategic Plan, and coordination of the National Vaccine Advisory Committee.  Funds These funds will be essential in securing full implementation of the National Vaccine Strategic Plan, a comprehensive roadmap in the development and use of vaccines across the life course in the United States.  

We look forward to working with your office as the FY23 appropriations process gets underway. For further information, please contact the AVAC managers at info@adultvaccinesnow.org. 

Sincerely, 

Alliance for Aging Research
American Academy of Family Physicians 
American College of Preventive Medicine 
American Heart Association
American Immunization Registry Association
American Pharmacists Association 
American Public Health Association
Asian & Pacific Islander American Health Forum
Association for Professionals in Infection Control and Epidemiology
Association of Asian Pacific Community Health Organizations (AAPCHO)
Association of Immunization Managers
Association of Maternal & Child Health Programs
Association of Occupational Health Nurses 
Association of State and Territorial Health Officials 
Biotechnology Innovation Organization
Dynavax
Families Fighting Flu
GSK
HealthyWomen
Hep B United
Hepatitis B Foundation 
Hepatitis Education Project 
Immunize.org 
Immunization Coalition of Washington, DC 
Infectious Diseases Society of America 
Johnson & Johnson
March of Dimes
Medicago 
Merck & Co Inc.
Moderna
National Association of City and County Health Officials
National Association of Nutrition and Aging Services Programs (NANASP) 
National Black Nurses Association
National Consumers League
National Foundation for Infectious Diseases
National Hispanic Medical Association 
National Minority Quality Forum
National Viral Hepatitis Roundtable 
Novavax
Pfizer 
Seqirus
STC Health
The AIDS Institute
The Gerontological Society of America
Trust for America’s Health
Vaccinate Your Family
Valneva USA
VBI Vaccines Inc.
WomenHeart: The National Coalition for Women with Heart Disease 

 

Cc: House Appropriations Committee 

      Senate Appropriations Committee 

 

 

Supporting Supplemental COVID-19 Funding

March 30, 2022

The Honorable Charles Schumer
Majority Leader
U.S. Senate
Washington, D.C. 20510

The Honorable Nancy Pelosi
Speaker
U.S. House of Representatives
Washington, D.C. 20515

The Honorable Mitch McConnell
Minority Leader
U.S. Senate
Washington D.C. 20510

The Honorable Kevin McCarthy
Minority Leader
U.S. House of Representatives
Washington, D.C. 20515

Dear Leaders:

On behalf of the Adult Vaccine Access Coalition (AVAC), we write to express our support for passage of COVID-19 supplemental funding to support ongoing COVID-19 vaccination efforts.

AVAC consists of over 70 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 to and utilization of adult immunizations.

Immunizations are a highly cost-effective form of preventive medicine that help save lives by protecting the health and wellbeing of individuals and families in communities nationwide. Over the last decade, advancements in technology, policy, and infrastructure have strengthened the immunization landscape. Vaccines have always been one of greatest public health achievements, but especially during the pandemic, where populations that are most vulnerable to the COVID-19 are also at greater risk of adverse health consequences from other vaccine preventable conditions. The devastating economic and personal toll of the COVID-19 pandemic is a stark and painful reminder of the impact of infectious disease on our families, communities, and global societies.

The COVID-19 pandemic continues to afflict individuals, families, and communities across the country, with many communities of color having been disproportionally impacted. Continuing the fight against COVID-19 requires collaboration from Congress and the Administration. The National COVID-19 Preparedness Plan initiated by the Biden Administration in February 2022 would ensure that the federal government has the capacity to make free and widely available life-saving tools such as vaccines.1 The Biden Administration initially requested $22.5 billion in COVID-19 funding to strengthen pandemic preparedness measures domestically and worldwide.

Without funding, the United States may not have enough additional booster shots, variant specific vaccines or second generation vaccines to protect against future waves of COVID-19. Appropriated funding is essential to continue vaccination campaign efforts, including support for health care providers to offer COVID-19 vaccines, boosters, and other routinely recommended vaccines without added barriers to access of an individual’s ability to pay for the vaccine. Most importantly, to promote public health goals, funding is needed for the COVID-19 Uninsured Program. This program will stop accepting COVID-19 vaccination claims for uninsured patients beginning on April 5, 2022 due to a lack of sufficient funds.

While the United States has made tremendous strides in the fight against COVID-19, the effort is not over. As our nation transitions to a new phase of the pandemic, one aimed at responding to new COVID-19 variants as they emerge and preparing for future pandemics, we must also work to ensure that individuals are up to date on their COVID-19 vaccines, boosters, and also receive other recommended vaccines that may have been missed during the pandemic.

It is critical that Congress expeditiously pass additional COVID-19 relief funding before a funding shortfall deters our nation’s recovery. Thank you for your consideration.

Sincerely,

Patricia M. D’Antonio
Vice President, Policy and Professional Affairs
The Gerontological Society of America
Co-Chair, Adult Vaccine Access Coalition

Phyllis Arthur
Vice President, Infectious Diseases & Emerging Science Policy
Biotechnology Innovation Organization
Co-Chair, Adult Vaccine Access Coalition

1 White House National COVID-19 Preparedness Plan. (2022). Available here.

AVAC Letter to OIDP Vaccines Federal Implementation Plan Public Comment

March 29, 2022 

David Kim, M.D. 
Office of Infectious Disease and HIV/AIDS Policy  
Department of Health and Human Services
200 Independence Ave. SW
Washington, DC  20201

RE: Vaccines Federal Implementation Plan Public Comment 

Dear Dr. Kim: 

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Office of Infectious Disease and HIV/AIDS Policy (OIDP) Request for Information (RFI) on the Vaccines Federal Implementation Plan (VFIP). The Vaccines National Strategic Plan (VNSP) presents an important framework of goals, objectives, and recommended vaccine strategies across the lifespan that will guide priority actions for the period 2021–2025. The implementation plan provides important markers to ensure the goals laid out in the VNSP will be measured and achieved.  

AVAC consists of over 70 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 to and utilization of adult immunizations.   

We appreciate that the VFIP continues the broad perspective of the NVSP on the entire vaccine enterprise, including the Department of Health and Human Services (HHS) move to adopt vaccine strategies across the lifecourse. The VFIP comes at a critical time as the COVID-19 pandemic has been a stark reminder of the cornerstone role immunizations play in disease prevention, response, and recovery efforts. Vaccines have a demonstrated record of success as a cost-effective means of reducing disease burden and saving lives, particularly among pediatric and older adult populations. Unfortunately, even before the pandemic, access to vaccines was not equal across a person’s lifespan. Indeed, adult vaccination coverage has lagged below federal health objective targets for most routinely recommended vaccines: influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, and HPV. Millions of adults suffer from vaccine-preventable diseases each year, causing them to miss work and leaving some unable to care for those who depend on them. On top of the already low rates, an estimated 37.1 million doses of recommended vaccines were missed during the pandemic.1 Avoidable illness costs individuals, families, communities, and our nation in numerous ways – not only in terms of lives lost, a deterioration in quality of life and increased disability, but also in terms of billions of direct and indirect costs to individuals, families, and our health care system.  The VFIP lays out a comprehensive roadmap to achieve improved access to and utilization of vaccines, especially through the reduction of technological, logistical, geographic, socio-economic, and financial barriers to the full complement of ACIP-recommended adult immunizations.   

Below we would like to offer a few overall perspectives and then provide specific focus on implementing goals 3 and 4, which fall most centrally as part of the work of our coalition.   

Goal Specific Comments:  

The objectives and strategies laid out in Goals 3 and 4 should be viewed and pursued in tandem, with close coordination among leads and support staff. Increasing knowledge of and confidence in recommended vaccines will help to increase community demand for immunizations and will be key to implementation success. The third goal highlights a key area where greater attention and concerted effort is desperately needed in the adult population. Education and awareness of the importance of immunizations should be intricately linked with efforts to improve access. While considerable progress has been made towards providing accurate, timely, and transparent information about COVID-19 vaccines through varied communications and partnership efforts, additional tools are needed to disseminate information about other recommended vaccines—including publication of evidence-based recommendations, use of mass media and new media, provider education and training, and support of non-federal stakeholder partners. These tools are essential to educating and increasing community demand for adult immunizations.  

Additionally, the VFIP has limited goals for assessing adult immunization status.  Despite broad recommendations for more than ten vaccines across the entire adult age range and for specific sub-populations, the VFIP has only four goals, one on immunization information systems, two on pneumococcal (high risk and 65+) and two on influenza (all adults and pregnant persons).  Consideration should be given to additional measures, even in a developmental manner, to better capture and track the full range of recommended vaccines across the lifecourse. 

Goal 3:  Increase knowledge of and confidence in routinely recommended vaccines  

3.1.1, 3.1.2, 3.1.3.  AVAC recommends additional presence of the Centers for Medicare and Medicaid Services (CMS) to provide additional leadership and support for Goal 3. CMS has a tremendous reach to millions of beneficiaries in Medicare and Medicaid and will be an essential partner in disseminating immunization information to providers and beneficiaries. Under strategy 3.1.1, CMS should play a lead role in the following action item. We would also request that older adults be listed in the group of stakeholders (see bolded language below). 

“Develop and disseminate regularly updated communication products (e.g., vaccine and vaccine safety updates and health equity–centered communication strategies for health care providers; fact sheets and other educational materials on vaccines, including those that counter mis- and dis-information) in multiple languages and media outlets to stakeholders, including Veterans, active-duty military personnel, older adults, persons with disabilities, and non-English speaker.”   

Additionally, CMS should also play a lead role in the last two action items under Strategy 3.1.1 by encouraging providers across health care settings to report immunization records and incentivizing the adoption of the National Vaccine Advisory Committee Standards for Adult Immunization Practice.2 

3.2.1. Increase provider capacity to promote knowledge of the benefits of immunization and increased vaccine acceptance by the public. This objective will be most impactful if barriers to access have also been effectively addressed. It appears 3.21 was not prioritized for a lead activity in the FVIP. AVAC would urge OIDP, CMS and Health Resources and Services Administration (HRSA) jointly lead the coordination and dissemination of information to the range of provider stakeholder organizations responsible for developing medical education curricula and standards. In addition to leveraging the direct lines of communication to their patients, healthcare professionals (HCPs) are trusted sources of information on how beneficiaries can safely receive preventative care. AVAC recognizes the importance of educating and informing HCPs at every stage of their education on the latest vaccine information, to ensure they are well informed, have confidence, and can make a strong recommendation to patients.  

3.2.3 Scale up implementation of best practices among health care providers to effectively promote vaccine confidence and vaccination uptake. This goal captures the broad and critical need to promote vaccine confidence and increase vaccine uptake.  This specifically calls out evidence-based counseling and technical assistance for health centers and in underserved communities.  Although these are all critical populations with high unmet needs, there should be additional actions to target childhood and adult vaccinations across the entire population. 

3.3.2.  Educate legislators, executive officers, and policymakers in jurisdictions on policies that increase vaccine use. The SAVE Lives Act is only one example of federal legislation to increase vaccine use. Section 3.3.2 should prioritize developing an “all of government” strategy to inform federal vaccine policy development overall. These relationships will go a long way towards demonstrating that the federal government is prioritizing all aspects of immunization policy. There is also a great need for key decision-makers to have research data as well as easy-to-understand and use information on vaccine benefits and risks, economics, and general attitudes towards adult vaccines.  

3.4.1.  Reduce barriers to data sharing between public health and the community (e.g., schools) to identify under-vaccinated populations. AVAC would encourage OIDP to expand upon its action items under this strategy to include greater emphasis on data collection in addition to reporting and sharing. In addition to challenges in data sharing between public health and communities, gaps in communication between public health, third party payers, and key decision- and policy-makers also persist. AVAC would also recommend the action items under this section of the VFIP include ONC, ASPR, IHS, VA and DOD as supporting partners to assist with managing, strengthening, and maintaining data standards and data sharing that help leverage coverage data to identify socially vulnerable communities.  

3.4.3.  Further develop, implement, and evaluate metrics to better understand vaccine confidence by age, race, ethnicity, disability, geography, education, and socioeconomic status over time. Special attention must be paid to advancing strategic, evidence-based metrics that measure whether activities are culturally appropriate and reflect the health literacy, language proficiency, and functional and access needs of specific target populations. AVAC therefore recommends that CDC and CMS lead this strategy with strategic support from the HHS and CMS Offices of Minority Health as partners on this strategy.  

3.4.4.  Engage trusted community members and organizations (e.g., faith-based leaders) within targeted communities to develop effective culturally and linguistically appropriate messages and strategies in those communities. We know that the best messengers within communities experiencing health disparities are the organizations and partners they already trust. Therefore, vaccination education campaigns must rely upon trusted local community leaders to extend health care messages to areas where people are least likely to be reached by traditional health care and where there are known pockets of vaccine hesitancy. It is vital that targeted resources are dedicated on an ongoing basis to enable local leaders to test and tailor proactive messages, while countering mis-and disinformation as well as anti-vaccination sentiments that may infiltrate communities. We recommend that additional actions and lead partners be added to 3.4.4, such as HRSA and the HHS Office of Minority Health, to make sure this important work happens in low access areas across the country.    

Goal 4:  Increase access to and use of all routinely recommended vaccines  

4.1.1.  Removing barriers to and incentivizing vaccination in a variety of settings will improve access to recommended vaccines, including in primary care practices, pharmacies, obstetrics-gynecology practices, other specialty health care settings, and non–health care settings such as schools, workplaces, places of worship, and community centers. AVAC recommends additional participation by CMS to help facilitate a diversity of vaccination settings. CMS has an essential role in helping to expand the number of immunizing providers, linking vaccination records, and promoting patient assessments. We urge CMS to serve as a lead partner under all the actions for this strategy.  

4.2.3. Increase use of data by public health departments and health care systems to identify and address disparities in vaccination rates in their jurisdictions and patient populations. Efforts to identify and address disparities will only be meaningful if consistent and reliable data is being collected and reported. At present, there is a great deal of variability in data elements being collected at an immunization encounter and the immediate needs for modernization of information technology platforms and software systems are also quite great. AVAC recommends including ONC as a lead partner with CDC and the VA to help improve systems relied upon to gather vaccination rates among sub-populations and to assist public health departments in their efforts to retrieve vaccination data from their Immunization Information System (IIS). We also recommend an additional action be included that is aimed at achieving better quality measurement and data collection.  

4.3.1.  Improve IIS reporting, its interoperability across jurisdictions, and bidirectional communication with other health data systems. AVAC agrees that the IIS must be improved and enhanced to meet new and changing data standards and access to IIS must be expanded to more providers and settings across the health care system. This expansion should be accompanied by education and technical assistance to facilitate reporting to the IIS. The immunization data collected across settings must also be efficiently and effectively shared with physician practices. As an additional action, AVAC recommends that IIS be fully integrated as a core pillar in the CDC Public Health Data Modernization Initiative and accompanying strategic implementation plan.3  

4.3.3.  Increase data analytics capacity to conduct disease surveillance and increase enrollment of adult health care providers in immunization information systems. AVAC encourages HHS in their annual budget to Congress to support investments in data analytics capacity to conduct disease surveillance and increase enrollment of adult health care providers in immunization information systems. AVAC recommends that the action accompanying this strategy be broadened to focus on reducing barriers to provider enrollment in the IIS and CMS be added as a supporting partner.  

4.4.5.  Remove system barriers to implementation of innovative services such as the use of mobile vans and telehealth and support adequate reimbursement for these services. AVAC recommends that community vaccination clinics be leveraged for the administration of recommended routine vaccinations beyond the COVID-19 pandemic to help with catch up doses that have been missed over the past two years.  Reporting to the IIS and sharing immunization records across providers should be included as part of the implementation of these innovative solutions to improve care continuity.    

4.5.2.  Promote adequate payments for vaccines and vaccinations by public and private health plans to incentivize providers to vaccinate, thereby promoting access. AVAC urges OIDP to include an action item for CMS to lead that is centered on building access through public plans based on the vaccine administration payment policy included in the calendar year 2022 Medicare physician fee schedule. AVAC also encourages the addition of an action item led by CMS to issue guidance to state Medicaid directors aimed at providing coverage and adequate provider payment for all routinely recommended vaccines.   

Overall Comments: 

  • AVAC members are thrilled to see the re-establishment of the Federal Interagency Vaccine Work Group (IVWG) during the creation of the NVSP in 2019. We are pleased members of the IVWG will continue this collaboration and have taken on distinct leadership responsibilities for the implementation of plan. To fully achieve metrics of success, we recommend that one member of the IVWG be chosen as lead for each strategy, with others listed as support for the action. The challenge with more than one lead is that it may not be clear who is on point for following through and achieving each action. 

  • We appreciate the VFIP prioritizing activities, indicators, and targets to achieve success. However, to fully achieve the elements of the plan, it must also provide budget estimates overall, and for lead partners specifically, so they can account for funds needed to undertake this work.  
  • The VFIP rightly lays out next steps, including reporting on the progress of activities within the plan. However, AVAC would recommend the inclusion of clear estimates and expectations on timelines between annual reporting cycles. Additionally, while the VFIP notes the first report is expected mid-2023, it does not offer a continued timeline for reporting between 2023 and 2025. We recommend an annual report be provided thereafter. 

  • AVAC appreciates that the VFIP recognizes the essential partnership between the federal government, immunization partners, and trusted community leaders and organizations. To achieve success, the IVWG members must continue to be proactive, clear, consistent, and highly visible in their communications to keep the public informed of vaccine development, safety processes, and approval and recommendation criteria.  

Again, thank you for the opportunity to provide comments on the federal governments’ implementation plan to strengthen and improve the nation’s response to vaccine preventable disease and strategies to address infectious disease through vaccination. Please contact the AVAC Coalition Managers Abby Bownas (abownas@nvgllc.com) or Lisa Foster (lfoster@nvgllc.com) if you would like more information about our views, or the work of AVAC. 

Sincerely,

Alliance for Aging Research
American Academy of Family Physicians
American Immunization Registry Association (AIRA)
American Lung Association
American Public Health Association
Biotechnology Innovation Organization (BIO)
Dynavax
Emily Stillman Foundation
Families Fighting Flu
GSK
HealthyWomen
Hep B United
Hepatitis B Foundation
Infectious Diseases Society of America
Kimberly Coffey Foundation
March of Dimes
Medicago
Meningitis B Action Project
Merck & Co Inc.
Moderna
National Association of Nutrition and Aging Services Programs (NANASP)
National Foundation for Infectious Diseases
National Viral Hepatitis Roundtable
Novavax
Sanofi
Seqirus
STChealth
The AIDS Institute
The Gerontological Society of America
Trust for America’s Health
WomenHeart: The National Coalition for Women with Heart Disease

January 10, 2022 
Carter Blakey
Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
1101 Wootton Parkway, Suite
420, Rockville, MD 20852 

Dear Director Blakey, 

Members of the Adult Vaccine Access Coalition (AVAC) and stakeholder partners, we appreciate the opportunity to offer comments on Healthy People 2030 and make recommendations to ensure that it reflects current public health priorities.  As a stakeholder coalition interested in improving the health and wellbeing of adults through better access to immunization services, we value the work happening around implementation of Healthy People 2030 and the opportunity to comment on newly proposed objectives as well as offer recommendations on new additional core measures.  AVAC would propose that two current developmental measures be adopted as core objectives, specifically the adult immunization status (AIS) and the life course Immunization Information Systems (IIS) measures. 

AVAC includes more than sixty-five organizational leaders in health and public health who are committed to addressing barriers to adult immunization.  AVAC works toward regulatory and legislative solutions that will strengthen and enhance access to adult immunization across the healthcare system. Our mission is informed by scientific and empirical evidence in support of the benefits immunizations provide by improving health, protecting lives against a variety of debilitating and potentially deadly conditions, and saving costs to the healthcare system and to society. A top priority for AVAC is to achieve increased adult immunization rates by encouraging compliance with federal benchmarks and performance measures that encourage utilization of recommended vaccines. 

Immunizations are a highly cost-effective form of preventive medicine that help save lives by protecting the health and wellbeing of individuals and families in communities nationwide. Since the Healthy People initiative began in 1979, there has been tremendous progress with respect to improved childhood immunization rates – one of the greatest public health achievements of the 20th century. Vaccine programs have contributed to the elimination of polio in the US and have dramatically reduced the spread of many more crippling and potentially life-threatening diseases such as diphtheria, tetanus, measles, mumps, and rubella. Vaccines also prevent the spread of common infectious and potentially fatal diseases such as chickenpox, influenza, hepatitis A, hepatitis B, meningococcal disease, pneumococcal disease, and whooping cough (pertussis). Vaccines not only help protect the immunized person but also those around them who may not be able to be immunized because they are too young to be vaccinated themselves or suffer from a health condition that prevents them from being immunized. When immunity levels in the population are high, the infectious agents do not circulate, which is known as herd immunity. Maintaining herd immunity is essential to protecting and preserving the health and wellbeing of individuals and entire communities from vaccine preventable conditions. 

Prior to the pandemic, more than 50,000 adults were dying each year from vaccine preventable diseases and thousands more suffered serious health problems. Despite Advisory Committee for Immunization Practices (ACIP) recommendations, vaccines are underutilized in the adult population for the most commonly recommended vaccines (influenza, pneumococcal, Tdap, hepatitis B, herpes zoster, human papillomavirus (HPV,) and meningococcal vaccines). At least 3 out of every 4 adults are missing one or more routinely recommended vaccines.  Disparities are even greater among at-risk populations, including seniors and people with chronic illness, as well as racial and ethnic underserved populations. Given the recognized health benefits of adult vaccinations and low rates of adult vaccination, made worse by the COVID-19 pandemic, coupled with the aging of the U.S. population, the impact of vaccine preventable conditions and their complications in adults is only expected to grow, with significant implications for the economy and society. Adult immunization is a core preventive health intervention that supports healthy aging and helps to avoid the costly effects of vaccine preventable illness. It is therefore imperative that as a nation we remain focused on improving adult vaccination rates. 

Over the past several decades, the Healthy People immunization and infectious disease objectives have been a cornerstone to national efforts to protect against vaccine preventable conditions across the lifespan. For example, as part of HP2020, the goal for flu vaccine coverage for adults 18 and over was 70% but the actual rate was closer to 45%, while the goal for pneumococcal vaccine coverage was 60% but the actual rate was closer to 25%. Healthy People objectives help to guide the actions of public and private stakeholders across the country who are committed to improving the health and wellbeing of our nation and provide a foundation for measuring progress. 

AVAC was disappointed when the initial slate of proposed Immunization and Infectious Disease (IID) objectives for Healthy People 2030 (HP2030) eliminated many critical immunization objectives, including Shingles, Pneumococcal, and Hepatitis vaccination. Recognizing that removing immunization objectives, at a time when vaccine preventable conditions were resurging in communities across the country and efforts to achieve HP2020 immunization goals for adults had largely stagnated, the final HP2030 included two developmental measures, including the Adult Immunization Status Measure (AIS) and a life course Immunization Information System (IIS) measure.   

IID-D03. Increase the proportion of adults age 19 years or older who receive recommended age-appropriate vaccines   

The Adult Immunization Status Measure (AIS) captures four immunizations in one (influenza, Td/Tdap, zoster and pneumococcal).  Having an adult composite is very much in line with the Healthy People 2030 plan to set national goals and measurable, evidence-based objectives to guide federal, state and local policies, programs and other activities to improve health and well-being. It would complement similar composite core objectives for children and adolescent immunization status and build out a lifespan approach to federal immunization efforts. At the same time, it would align HP2030 objectives with external health care quality measurement tools, streamlining the patchwork of existing adult immunization measures, reducing the reporting burden to providers, and providing a meaningful national picture of access to this important preventive service.  We urge HHS to initiate a process to transition this measure from a developmental to a core Immunization and Infectious Disease (IID) objective in 2022.   

Recognizing that developmental measures are those categorized as “not yet having reliable baseline data,” we believe the AIS has a record for inclusion.  As you know, the HHS National Vaccine Program Office (NVPO) and the CDC, in collaboration with the National Adult Immunization and Influenza Summit, developed and tested this composite measure based on one previously utilized by the Indian Health Service.  In November 2021, it was included for adoption by health plans in the Healthcare Effectiveness Data and Information Set (HEDIS), one of healthcare’s most widely used performance improvement tools.  With an estimated 26 million doses of recommended vaccines missed during pandemic1, now is the time to implement this important AIS measure and help our health care providers take steps necessary to ensure that adult patients are fully immunized and have maximum protection from serious disease by assessing immunization status at every clinical encounter and making a strong recommendation for vaccines needed; administering needed vaccines or referring to a provider who can immunize; and, document vaccines administered or received in the immunization information system (IIS).   

IID-D02.  Increase the proportion of immunization information systems that track adult immunizations across the lifespan 

 Immunization Information Systems (IIS) are confidential systems that are an essential part of the immunization infrastructure. IIS play a critical role in creating a comprehensive consolidated immunization record, assisting with vaccine evaluation, and forecasting, generating patient reminders, assessing vaccine uptake, providing schools and childcare providers access to consolidated records, assisting with vaccine ordering and inventory management, supporting outbreak investigation, calculating vaccine coverage estimates, and much more.  Improving IIS utilization can lead to increased vaccination rates, contributing to the overall goal of reducing vaccine preventable disease.  Immunization providers rely on IIS to implement an increasingly complex vaccination schedule, as well as monitor vaccine safety, efficacy, and vaccine delivery. The broad availability of immunization data through real-time Electronic Health Record (EHR)-IIS query significantly lowers the burden (and cost) to providers in accessing immunization records and forecasts at the point of care.   

Moving the lifespan IIS objective from the developmental to the core Immunization and Infectious Disease (IID) objective set will elevate the importance of immunization record capture for all individuals into an IIS as a national priority.  At the same time, it can help to eliminate disparities by promoting more accurate evaluation of coverage gaps across the country.   Since immunizations are a cornerstone for protecting the public’s health, and given the growing importance of health information technology, there should be a commitment to supporting the IIS reporting objective across the life course.  We urge that IID-D02 be moved from developmental to reporting objective in 2022. 

New Public Health Infrastructure Objectives 

AVAC also would like to take a moment to express support for the two proposed objectives to improve public health infrastructure in tribal communities: 

Public Health Infrastructure-NEW-08: Increase the proportion of tribal communities that have developed a health improvement plan. (Data source: Public Health in Indian Country Capacity Scan, National Indian Health Board) 

Public Health Infrastructure-NEW-09: Increase the proportion of tribal public health agencies that use Core Competencies for Public Health Professionals in continuing education for personnel. (Data source: Public Health in Indian Country Capacity Scan (PHICCS), National Indian Health Board) 

While these new objectives encompass more than just vaccination, AVAC believes they are important to improve health equity for tribal communities and strengthening of public health in these communities. 

Again, thank you for this additional opportunity to comment on HP2030 and to offer our support for moving the AIS and IIS measures from developmental to core objectives as well as support for the proposed public health infrastructure objectives.  AVAC believes the AIS and IIS objectives will help our nation to achieve and maintain a strong emphasis on vaccines as part of Healthy People 2030 federal health benchmark goals. We believe now is the time to make immunization coverage across the lifespan a shared national priority and goal that all stakeholders in the health care system should be striving for over the coming decade. Please contact the AVAC Coalition Managers at (202) 540-1070 or info@adultvaccinesnow.org if you wish to further discuss our comments. To learn more about the work of AVAC, visit www.adultvaccinesnow.org. 

Sincerely,

American Academy of Family Physicians
American Public Health Association
Asian & Pacific Islander American Health Forum
Association for Professionals in Infection Control and Epidemiology
Center for Sustainable Health Care Quality and Equity
Dynavax
Families Fighting Flu
GSK
HealthyWomen
Hep B United
Hepatitis B Foundation
Immunization Action Coalition
Immunization Coalition of Washington, DC
Medicago
Merck & Co Inc.
National Association of County and City Health Officials
National Association of Nutrition and Aging Services Programs
National Consumers League
National Foundation for Infectious Diseases
National Viral Hepatitis Roundtable
Novavax
Sanofi
Seqirus
STCHealth
Takeda Vaccines, Inc.
The Gerontological Society of America
Trust for America’s Health
Vaccinate Your Family  

AVAC Supports Section 139402 and Section 139405 of the Build Back Better Act

The Adult Vaccine Access Coalition sent the below letter to Majority Leader Schumer in support of key provisions in the Build Back Better Act for adult immunizations.

December 13, 2021

The Honorable Charles Schumer
Majority Leader
U.S. Senate
Washington, D.C. 20510

Dear Majority Leader Schumer:

Thank you for your strong support and leadership in improving access to vaccines for older adults and individuals with chronic conditions who rely on federal programs for vaccine coverage. We are grateful that the Build Back Better Act includes two provisions that will greatly improve access to important preventative vaccines for our most vulnerable populations.

  • Section 139402 would provide first dollar coverage of adult vaccines recommended by the Advisory Committee on Immunization Practices under Medicare Part D; and
  • Section 139405 would improve access to adult vaccines under Medicaid and CHIP by providing a federal baseline for first dollar coverage and an enhanced FMAP for immunizing providers.  

Longstanding inequities in vaccine coverage, particularly for adults, has hindered our nation’s disease prevention efforts and put older adults and persons with chronic conditions needlessly at risk of the serious health consequence of vaccine preventable illness. The COVID-19 pandemic laid bare these inequities and last year, Congress rightly made sure that COVID-19 vaccines would be available to everyone with no patient cost-sharing.

Likewise, Section 2713 of the Public Health Service Act (PHS Act) added by the Patient Protection and Affordable Care Act (ACA) removed cost-sharing and co-pays for vaccinations recommended by the Center for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) for all compliant private plans. However, until now, Medicare and some Medicaid beneficiaries were left out of this change, leaving many to face high out-of-pocket costs for vaccinations.

The Build Back Better Act will remedy this longstanding inequity, by eliminating financial barriers to all ACIP recommended vaccines in Medicare Part D and by providing coverage and eliminating cost sharing for adults in traditional Medicaid. These provisions will go a long way to improve the underlying health of the communities most at risk for COVID-19 and aid the elimination of racial disparities in health care, and are supported by a diverse group of immunization stakeholders.

Again, we are grateful for your leadership in taking this important step.  Members of AVAC stand ready to work with you, because we believe a fully vaccinated public is an investment in our future health, wellbeing and economic success of our nation.

Sincerely,

Adult Vaccine Access Coalition
Alliance for Aging Research
American Academy of Family Physicians
American Behcet’s Disease Association (ABDA)
American Lung Association
American Society on Aging
Asian & Pacific Islander American Health Forum
Association for Professionals in Infection Control and Epidemiology
Association of Asian Pacific Community Health Organizations (AAPCHO)
Association of Immunization Managers (AIM)
California Immunization Coalition
Caregiver Action Network
Caring Ambassadors Program
Cascade AIDS Project
Dynavax
Families Fighting Flu
Forward Pharmacy
Geriatric Medicine PAs
Global Healthy Living Foundation
HealthHIV
Healthy Men Inc.
HealthyWomen
Hepatitis B Foundation and Hep B United
Hispanic Federation
Idaho Immunization Coalition
Immunize Colorado
Immunize.org (IAC)
ImmunizeTN
Justice in Aging
Kelsey-Seybold Clinic
Kimberly Coffey Foundation
Lupus and Allied Diseases Association, Inc.
National Association Of County and City Health Official
National Association of Nutrition and Aging Services Programs (NANASP)
National Black Nurses Association
National Caucus and Center on Black Aging
National Coalition for LGBTQ Health
National Consumers League
National Council of Urban Indian Health (NCUIH)
National Council on Aging
National Education Association
National Hispanic Medical Association
National Viral Hepatitis Roundtable (NVHR)
North Carolina Immunization Coalition
Patient Access Network (PAN) Foundation
RetireSafe
STChealth
The AIDS Institute
The Gerontological Society of America
Triage Cancer
Trust for America’s Health
University of Wisconsin-Madison
Vaccinate Your Family
Vaccine Ambassadors
Valneva, USA
VaxCare
WomenHeart: The National Coalition for Women with Heart Disease

Cc: Democratic members of the United States Senate

AVAC Submits Comments on the Hospital Outpatient Prospective Payment

On September 17, AVAC submitted comments on Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; etc.

To Whom It May Concern: 

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; etc. 

Specifically, AVAC wishes to highlight its strong support for the following proposals included in this proposed rulemaking: 

  • Adoption of a COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure for the Hospital OQR and ASCQR Program Measure Sets Beginning with the CY 2022 Reporting Period/CY 2024 Payment Determination 
  • Greater use of electronic clinical quality measures (ecQMs) across health care programs managed by HHS. 
  • Potential Future Efforts to Address Health Equity in the Hospital OQR and the ASCQR Programs to include bolstering immunization through the following actions:
    • Facilitating dissemination and adoption of the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice; 
    • Encouraging CMS to work with the HHS Office of Disease Prevention and Health Promotion to incorporate the increase in the proportion of adults age 19 or older who get recommended vaccines developmental measure2 in its strategy to close equity gaps for adult immunization and; 
    • Supporting CMS’ proposed use of Quality Improvement Networks and Quality Improvement Organizations (QIN-QIOs) as a means to address the core priority areas outlined in the CMS Equity Plan for Improving Quality in Medicare to address inequities and gaps in access to adult immunization. 

AVAC consists of over 60 organizational leaders in health and public health that are committed to driving federal policy changes that will strengthen and enhance access to adult vaccines and awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions through 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. 

COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure 

AVAC appreciates the opportunity to express strong support for CMS’ proposal to add a new COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure to the FY 2023 Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgical Center Quality Reporting (ASCQR) Programs. The COVID-19 pandemic had a disproportionate and devastating impact on communities of color and older adults. This new measure would require hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) to report on COVID-19 HCP vaccination rates to assess to what extent these facilities are taking steps to limit the spread of COVID-19 among their HCP, reduce the risk of transmission within their facilities so they can continue to serve their communities throughout the COVID-19 Public Health Emergency (PHE) and beyond. Under this proposal, HOPDs and ASCs would report the vaccination data through the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN) beginning October 1, 2021 through December 31, 2021. 

AVAC believes this measure is vitally important to protect the health and wellbeing of our community, particularly older adults and individuals with chronic conditions. Reporting of the COVID-19 for HCP measure through the NHSN will help ensure transparency and accountability in community infection prevention and control efforts and is consistent with other HCP vaccination measures intended to preserve health and mitigate infectious disease outbreaks in the healthcare setting. 

We know from reporting of influenza vaccination coverage of HCPs that uptake of the vaccine is also associated with those providers recommending vaccination to their patients, which in turn encourages greater patient vaccination uptake. HCP vaccination can also potentially reduce illness-related missed work and disruptions to patient care. Lastly, reporting of HCP vaccination rates helps inform patients and caregiver choice when considering facilities from which to seek care, particularly for those at high-risk for developing serious complications from COVID–19. AVAC believes the COVID-19 HCP vaccination measure should be included efforts to assess and reduce the risk of transmission of COVID–19 within healthcare settings and urges CMS to maintain this proposal in the final rule. 

The proposed rule includes a shortened reporting period of October through December 2021. AVAC supports the proposed timeframe and appreciates that the COVID-19 HCP reporting period and measure specifications align closely with the Influenza HCP vaccination measure (NQF 0431). 

Fast Healthcare Interoperability Resources (FHIR) in support of Digital Quality Measurement in Quality Reporting Programs – RFI 

AVAC appreciates the work of the Department of Health and Human Services to “encourage and support the adoption of interoperable health information technology and to promote nationwide health information exchange to improve health care and patient access to their health information.” Promoting the use of consistent patient data sets across health care settings can be vitally important to ensure quality patient care and health outcomes while reducing the reporting burden on providers. Additionally, timely and accurate reporting of immunization record data is also of utmost importance for public health disease surveillance and outbreak prevention activities. Consistent data collection and reporting is a foundational element for successful quality measurement, transparency, and accountability. 

AVAC fully supports greater use of electronic clinical quality measures (ecQMs) across health care programs managed by HHS, including the Centers for Medicare and Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), among other agencies. As CMS seeks feedback on definitions for digital quality measures (dQMs) for HOPDs, we would encourage CMS to look to existing ecQM resources that are available through the National Coordinator for Health Information Technology and as well as uniform data system modernization efforts within the Bureau of Primary Health Care at HRSA. Greater consistency in the adoption and use of electronic quality measures and a common reporting standard across HHS programs that serve vulnerable populations of all ages and across health care settings will improve overall quality of patient care, drive better health outcomes, as well as inform and empower patients, without creating an additional complexity and reporting burdens on health care providers. 

In terms of vaccine data for patients in HOPDs and ASCs, AVAC supports incentivizing interoperable and bidirectional immunization data reporting to immunization information systems, leveraging tools and measures through the hospital OQR and ASCQR programs. Provider, patient and caregiver access to immunization record data is essential to addressing health inequities in immunization coverage for the COVID-19, as well as the range of routinely recommended vaccines important to protecting the health and wellbeing of Medicare beneficiaries in the hospital outpatient and ASC care settings. 

Quality measurement programs through Medicare play a critical role in promoting improved quality and encouraging adherence to and consistent utilization of recommended health care interventions, including adult vaccines. Vaccines play a vital role in preventing illness and death, reducing caregiving demands, avoiding unnecessary healthcare spending, and setting the foundation for healthy aging. 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 across the lifecourse, especially given the COVID-19 pandemic and annual flu seasons. 

Request for Comment on Potential Future Efforts to Address Health Equity in the Hospital OQR and the ASCQR Programs 

AVAC appreciates the opportunity to respond to the request for comment on addressing health equity in the Hospital OQR and ASCQR programs discussed in the proposed rule. Even before the COVID-19 pandemic, vaccine preventable illness devastated the lives of thousands of adults each year, particularly older adults, and those with underlying health conditions. Vaccine preventable conditions not only affect the patient but also their family members, caregivers, and friends. Prior to the pandemic more than 50,000 adults died from vaccine-preventable diseases each year in the United States. While adult coverage has lagged Healthy People targets for most routinely recommended vaccines. Disparities in adult vaccination coverage rates are even more acute when broken down by age, race, ethnicity, socioeconomic status and geography. 

A recent examination of National Health Interview Survey data of adult immunization rates between 2010 and 2019 found persistent disparities of adult vaccination rates among racial and ethnic minority populations. According to the study, “Influenza vaccination coverage differed by race/ethnicity among adults aged ≥65 years (61.4% for Black, 63.9% for Hispanic, 71.9% for Asian, and 72.4% for White adults). Pneumococcal vaccine coverage in Black (57.7%), Hispanic (51.4%), and Asian (49.0%) individuals was lower than that in White (71.1%) individuals. Tdap and zoster vaccine coverage also differed by race/ethnicity.” Low household income and low education levels were also associated with lower immunization rates. 

Unfortunately, as result of the pandemic, routine vaccination rates, across all ages, have eroded further, leaving communities vulnerable to preventable disease, illness, and outbreaks. An analysis found that adult and adolescent Centers for Disease Control and Prevention (CDC) recommended vaccines declined between 41%-53% from March-August 2019 as compared to March-August 2020.7 Weekly vaccination rates among Medicare beneficiaries also declined drastically (70%–89% below 2019 rates) Long-standing health disparities are also laid bare in these trends. Further, data indicate that 35% of Black Americans and 42% of Hispanic Americans report wanting to receive the COVID-19 vaccine compared to 53% of white Americans.8 Meanwhile, Black Americans and Hispanic Americans are proportionally receiving less COVID-19 vaccinations than their share of the total population. These trends have had serious consequences on our nation’s ability to achieve herd immunity, resulting in continued outbreaks across the country. We are grateful for CMS’ commitment to addressing systemic inequities that have resulted in poor health outcomes for certain populations and look forward to working with the agency on this important goal. 

As CMS looks for ways to address health equity in the context of the Hospital OQR and ASCQR programs, AVAC would urge CMS to consider the following actions with regard to immunization: 

  • Promote dissemination and adoption of the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice1. This standard of practice for immunizations would ensure that Medicare beneficiaries have equitable access to information about recommended vaccines and the opportunity to receive those vaccines from a trusted health care provider. Consistent assessment of immunization status through adoption of NVAC adult standards of care and implementation of adult immunization status measure are vital components to addressing longstanding disparities in access to immunization and will ensure that all Medicare beneficiaries receive a strong immunization recommendation from their provider and have the resources they need to make an informed decision. Widespread implementation of the NVAC Standards for Adult Immunization Practice is also an important first step toward advancing the Healthy People 2030 developmental measure to increase the proportion of adults age 19 or older who get recommended vaccines (IID-D03). 
  • Another important element to closing the equity gap is consistent data collection and real-time reporting. The COVID-19 pandemic has illustrated the need for investments in our nationwide immunization data framework, as well as the dissemination and adoption of federal guidelines and incentives to encourage consistent reporting and widespread utilization of immunization information systems (IIS) across provider settings. In order to effectively identify and address health equity gaps, there must be strong and clear criteria in place for data reporting elements, provider usage, along with baseline standards interoperability, bidirectional exchange, data quality and security. 
  • AVAC encourages CMS to work with the HHS Office of Disease Prevention and Health Promotion to include the Healthy People 2030 lifespan IIS reporting3 developmental measure in the Hospital OQR and ASCQR programs to close equity gaps for adult immunization in these outpatient care settings. Robust immunization record data reporting will empower providers, patients and caregivers to make educated decisions about vaccinations, reduce missed opportunities for immunization, minimize the likelihood of overvaccination, and help inform health care system efforts to close health equity gaps and prevent disease outbreaks. 
  • Lastly, AVAC also expresses support for the use of Quality Improvement Networks and Quality Improvement Organizations (QIN-QIOs) as a means to address the core priority areas outlined in the CMS Equity Plan for Improving Quality in Medicare. The three priority areas which inform CMS policies and programs are: (1) Increasing understanding and awareness of health disparities; (2) developing and disseminating solutions to achieve health equity; and (3) implementing sustainable actions to achieve health equity. The QIN-QIOs have a demonstrated track record of success in testing and evaluating innovative and effective strategies for improving immunization coverage rates among targeted Medicare populations. AVAC encourages CMS to continue to utilize the QIN-QIOs for this purpose and urges CMS to include in the list of tasks outlined in future scopes of work (SOW) strategies to improve immunization coverage rates among hard to reach rural and geographically underserved areas as well as among disabled, homebound, inpatient and congregate care patient populations. 

Thank you again for the opportunity to share our perspective on this proposed rule. Please contact an AVAC Coalition Manager at (202) 540-1070 or lfoster@adultvaccinesnow.org if you wish to further discuss our comments. To learn more about the work of AVAC visit www.adultvaccinesnow.org. 

Sincerely, 

American Immunization Registry Association (AIRA) 
Alliance for Aging Research 
Biotechnology Innovation Organization 
Dynavax Technologies Corporation 
Families Fighting Flu 
GSK 
Immunization Action Coalition 
Infectious Disease Society of America 
Medicago 
Merck & Co Inc. 
National Association of Nutrition and Aging Services Programs 
National Consumers League 
Novavax 
Sanofi 
STChealth LLC 
The Gerontological Society of America i 
Trust for America’s Health 

AVAC Offers Comments on the CY2022 Physician Fee Schedule

On September 13, 2021, AVAC submitted a letter to Centers for Medicare & Medicaid Services offering comments on the Medicare Program: CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; Provider and Supplier Prepayment and Post-Payment Medical Review Requirements.

 September 13, 2021 

RE: CMS-1751-P Medicare Program: CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; Provider and Supplier Prepayment and Post-Payment Medical Review Requirements 

To Whom It May Concern: 

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on Medicare Program: CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; Provider and Supplier Prepayment and Post-Payment Medical Review Requirements. 

Specifically, AVAC: 

  • Greatly appreciates the Centers for Medicare and Medicaid Services (CMS) recognition of stakeholder concerns about the reduction in Medicare payment rates for vaccine administration over the past several years. 
  • Encourages CMS to utilize the OPPS $40 payment for COVID-19 vaccine administration and for all routinely recommended vaccines. 
  • Urges CMS to bolster efforts to close the Health Equity Gap for immunization through the following actions:
    • Facilitating dissemination and adoption of the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice;
    • Encouraging CMS to work with the HHS Office of Disease Prevention and Health Promotion to incorporate the increase in the proportion of adults age 19 or older who get recommended vaccines developmental measure2 in its strategy to close equity gaps for adult immunization and; 
    • Supporting CMS’ proposed use of Quality Improvement Networks and Quality Improvement Organizations (QIN-QIOs) as a means to address the core priority areas outlined in the CMS Equity Plan for Improving Quality in Medicare to address inequities and gaps in access to adult immunization.
  • Encourages CMS to work with ONC on implementation of the proposal to make the Immunization Registry Reporting a required measure under the Public Health and Clinical Data Exchange objective of the Promoting Interoperability performance category beginning with the performance period in CY 2022.

AVACs broad membership consists of over sixty-five 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. Despite the well-known benefits of immunizations, prior the pandemic than 50,000 adults died from vaccine-preventable diseases annually, while adult coverage consistently lag behind federal targets for most recommended vaccines: influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, and HPV. 

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. One of our key coalition priorities is to advocate for federal benchmarks and quality measures to encourage improved tracking and reporting of adult immunization status that will result in increased adult immunization rates. 

The devastating economic and personal toll of the COVID-19 pandemic is a stark and painful reminder of the impact of infectious disease on our families, communities, and global societies. It is important to note, however, that outbreaks of common vaccine-preventable conditions, such as influenza and pneumococcal, also take a toll each year. The Centers for Disease Control and Prevention (CDC) estimates that influenza was associated with more than 48.8 million illnesses, more than 22.7 million medical visits, 959,000 hospitalizations, and 79,400 deaths during the 2017–2018 influenza season with the majority of deaths in older adults age 65 years and older. Moreover, direct medical costs related to influenza disease are estimated at about $10.4 billion, rising to $87 billion when loss of work and life are included.

Additionally, invasive pneumococcal disease causes approximately 29,500 cases a year and 3,350 deaths. Ninety percent of cases and nearly all deaths are in adults 65 years and older. The cost of pneumococcal disease in those 65 and older equates to $3.8 billion each year 

with an additional $11 billion added for those aged 50-64 years. These numbers do not take into account costs associated with sequelae such as heart attack and stroke, which recent research has linked to respiratory diseases such as influenza and pneumonia, nor the cost of the 1 million cases of shingles. 

The economic losses from avoidable doctor visits, hospitalizations and lost income highlight the exceptional value of vaccine services. For example, in the 2013-2014 influenza season, with vaccination rates of 41%, vaccine efficacy of 61%, and a predominant H1N1 season which hit younger and middle-aged adults particularly hard, vaccination prevented 7 million illnesses, and 90,000 hospitalizations. Vaccines are highly effective at preventing severe illness, morbidity and mortality. 

Vaccine Administration Services – Medicare Part B Vaccines 

The proposed rule rightly notes, the public health emergency (PHE) for COVID-19 has reinforced the important and positive impact that preventive vaccines can have on the health of Medicare beneficiaries and the broader public. The development of COVID-19 vaccines and national efforts to immunize millions of Americans has altered the landscape for vaccines and vaccine administration. For example, by encouraging existing providers and suppliers to dramatically expand their vaccination capabilities and by encouraging new (and new types) of providers and suppliers to furnish vaccines. 

AVAC has long supported making all routinely recommended vaccines widely available to Medicare beneficiaries by enabling providers from across the health care system to participate in the immunization ecosystem. AVAC appreciates that the CY22 proposed rule acknowledges stakeholder concerns about the reduction in Medicare payment rates for vaccine administration over the past several years and requests feedback toward the development of a long-term rate that acknowledges and supports the value of vaccine services across different provider sites. 

Rates for vaccine administration currently vary by setting. For HCPCS codes G0008, G0009 and G0010, the CY 2021 national average payment rate for physicians, practitioners and other suppliers is $16.94, which is geographically adjusted, while for hospital outpatient departments it is $40. However, for COVID-19 vaccine administration, Medicare now pays $40 per administration in all provider settings. The proposed rule asks a series of thoughtful questions, including, “should Medicare continue to pay differently for non-COVID-19 preventive vaccines furnished in certain settings or under certain conditions? If not, what factors contribute to higher costs for administration of non-COVID-19 vaccines that are not currently reflected in the Medicare payment rates?” 

Given the fact that vaccine services are not included within the statutory definition of physicians’ services in section 1848(j)(3) of the Act, CMS has historically based payment rates for the administration for preventive vaccines by physicians, NPPs, and mass immunizers on an evaluation of the resource costs involved in furnishing the service, similar to the methodology used to establish payment rates for the physician fee schedule. As noted, CMS also assigns a payment rate for administering these preventive vaccines under the Outpatient Prospective Payment System (OPPS) for hospitals and home health agencies that are based on claims data. 

As the proposed rule notes, payment rates for the three Healthcare Common Procedural Coding System (HCPCS) codes G0008, G0009, and G0010, which describe the services to administer an influenza, pneumococcal and HBV vaccines, respectively, have been based on a direct crosswalk with CPT code 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). However, when CMS finalized reductions in valuation for 96372 in CY 2018, and the payment rate for the vaccine administration codes was concurrently reduced. Further, because the reduction in RVUs for CPT code 96372 was significant enough to be required to be phased in over several years under section 1848(c)(7) of the Act, the reductions in overall valuation for the vaccine administration codes were likewise subject to reductions over several years. As a result of these changes in the reimbursement rate for CPT codes for vaccine administration, the proposed reductions would have resulted in a cumulative 44 percent reduction in reimbursement over a three-year period. 

Considering the significant potential impact on access to vaccine services, AVAC and other interested stakeholders expressed deep concern to the proposed changes during previous regulatory comment periods. Consequently, CMS did not implement payment reductions for vaccine administration in either the CY2020 or CY2021 final rules. CMS also did not move forward with a proposal in the final CY2021 PFS rule to decouple the practice expense RVU for vaccine administration from therapeutic injection (96372) if favor of a crosswalk between the valuation of vaccine administration CPT codes 90460, 90471, and 90473 and HCPCS codes G0008, G0009, and G0010 to CPT code 36000 (Introduction of needle or intracatheter, vein). 

AVAC appreciates CMS’ desire to allow the RUC process to review vaccine administration services covered by CPT codes 90460 (Administration of first vaccine or toxoid component through 18 years of age with counseling), 90471 (Administration of 1 vaccine), and 90473 (Administration of 1 nasal or oral vaccine), as well as provide recommendations for how to value the CPT codes that describe the service to administer the COVID-19 vaccines. 

As CMS looks to develop an accurate and stable payment rate for administration of the preventive vaccines described in section 1861(s)(10) of the Act for physicians, NPPs, mass immunizers and certain other providers and suppliers, AVAC urges the agency to think comprehensively about vaccine services across the immunization neighborhood and not inadvertently create disincentives from certain providers offering vaccines. Specifically, AVAC urges CMS to move forward with a payment rate for physicians, practitioners, and other suppliers equal to the $40 per administration OPPS payment rate for the COVID-19 vaccine administration as well as for vaccine administration of other routinely recommended ACIP vaccines. 

A $40 per dose payment rate for vaccine administration more appropriately reflects the high value of vaccine services and would improve access to recommended vaccines for Medicare beneficiaries. The current cost-based methodology for determining vaccine administration payment rates has resulted in suboptimal and inequitable vaccination rates, costly vaccine preventable disease, and financial strain for vaccine providers. Moving away from a cost-based methodology would give providers with more flexibility to provide additional counseling services or implement innovative clinical workflows to optimize vaccination among their patients. 

Given the high value of vaccine services, AVAC urges CMS to encourage more utilization among adults in all health care settings. Greater utilization of vaccines results in less downstream spending in terms of avoidable hospitalizations, doctor visits and medications necessary to treat conditions that vaccines are designed to prevent. Vaccines also provide better health outcomes. Utilizing the OPPS vaccine payment rate of $40 per dose will provide support for more providers to offer vaccinations and may help improve vaccination rates among beneficiaries. 

Alternatively, CMS could consider moving forward with the crosswalk valuation of CPT codes 90460, 90471, and 90473 and HCPCS codes G0008, G0009, and G0010 to CPT code 36000 (Introduction of needle or intracatheter, vein) that was originally included in the CY2021 proposed PFS rule. The proposed crosswalk with CPT code 36000 would represent a more accurate valuation of vaccine services and would also serve to ensure more appropriate relative resources involved in furnishing all these services is reflected in the payment. 

As you know, there has been a significant reduction in routine immunizations across the life course due to COVID. An analysis by Avalere Health found than 26 million doses of recommended vaccines were missed from January through November.6 While practices are starting to rebound in terms of patient visits, immunization rates among adults have not fully rebounded to pre-pandemic level. Earlier this year, CMS rightly recognizes that adequate reimbursement for providers is critical and that over the long-term, there needs to be a payment rate that prioritizes vaccine services for the individual, community and societal value provided. Equitable and sustained payment rates for vaccine services are vital to delivery and supporting the range of Medicare providers who are an integral part of that effort. 

Vaccine Administration Services with Federally Qualified Health Centers (FQHCs) 

Federally Qualified Health Centers (FQHCs) are a vital source of health care for low-income and underserved populations and are an important community partner in COVID-19 and routine vaccination efforts. As we have noted in previous rulemaking comments, the current structure and timing of FQHC reimbursement for vaccines through cost reports serves as a disincentive to the provision of vaccine services. In the short-term, AVAC urges CMS to amend the FQHC cost report and instructions to ensure FQHCs receive Medicare reimbursement at 100% of the reasonable costs for the COVID-19 vaccine and its administration and Medicare Advantage enrollees’ vaccine administration. 

AVAC appreciated that CMS recognized FQHC vaccine reimbursement challenges, and in April 2021 issued guidance permitting FQHCs to request lump-sum payments from their Medicare Administrative Contractors (MACs) for administering the COVID-19 vaccine in advance of cost report settlement. We are grateful for this important first step and encourage CMS to remain vigilant in its oversight of FQHC lump-sum payments to address some of the challenges health centers are experiencing with burdensome reporting requirements, data collection, and slow distribution from the MACs. 

To address the cost report delays and challenges on a permanent basis, AVAC also strongly encourages CMS to amend the FQHC cost report template and instructions to reflect accurate cost reimbursement for the COVID-19 as well as other routinely recommended vaccines. Health centers are beginning to incorporate vaccinations into routine primary care visits, and within the next few weeks will begin providing COVID-19 booster shots to Medicare patients. It is imperative that CMS amends the cost report establishing a permanent reimbursement mechanism for COVID-19 and other vaccines as health centers continue to provide these important preventive services in the future. Amending 42 C.F.R. §405.2466(b)(1)(iv) and its cost reporting instructions will ensure health centers will be adequately reimbursed for serving the Medicare population throughout the pandemic and beyond. 

AVAC also urges CMS to acknowledge the additional costs associated with COVID-19 vaccine administration. It requires more resources, logistical planning, and patient education. Given lower vaccination rates for routine vaccines, such as flu and pneumococcal, among adults in black and brown communities, AVAC would encourage CMS to explore amending cost reporting instructions to permit health centers to account for the total amount of staff time and clinical costs incurred for the COVID-19 vaccine as well as other routinely recommended vaccines. Medicare Advantage should also be added to the cost report to ensure health centers receive adequate reimbursement for serving Medicare populations. 

The current CMS cost report assumes that the vaccine administration consumes no more than five minutes of clinical time. It is important that FQHCs have the time necessary to address the range of factors associated with administering the COVID-19 and other recommended vaccines to Medicare patients. As such, CMS should amend the cost report template to account for at least 30 minutes of clinical time per administration and should also provide program instructions on the reconciliation of lump-sum payments to the costs reflected on the cost report vaccine payment worksheet. 

Vaccine Administration Services – Payment for COVID-19 Vaccine Administration in the Home 

AVAC strongly supports the new add-on payment COVID–19 vaccine administration in the home and encourages CMS to consider expanding this add-on payment to all routinely recommended Part B vaccines. The new national add-on payment rate of $35.50 for COVID–19 vaccines that are administered by a provider in the beneficiary’s home will be important for beneficiaries to remove the barriers to COVID-19 vaccinations and to deliver vaccination to 

beneficiaries who are not able to leave the home due to medical or cognitive limitations, or other challenges such as lack of access to reliable transportation or reside in hard-to-reach areas. Under this new policy, providers administering a COVID–19 vaccine in the home will be paid a national average payment $75.50 dollars per dose ($40 for COVID–19 vaccine administration and $35.50 for the additional payment for administration in the home, both payments are geographically adjusted). 

We agree with CMS that basing the COVID-19 vaccine administration add on payment on the home health low utilization payment adjustment (LUPA) is a reasonable proxy for the additional resource costs associated with administering COVID-19 vaccines in a beneficiary’s home. AVAC urges the agency to maintain the add-on payment for COVID-19 vaccine services beyond the PHE and encourage CMS to consider expanding the add on payment to other routinely recommended vaccines for older adults. Expanding this add on payment to other recommendation vaccines could help support clinicians’ ability to offer vaccines in patients’ homes and drive vaccine uptake among individuals with chronic illnesses and those with mental and physical disabilities that severely limit their mobility and their ability to seek vaccination services outside the home setting. Racial and ethnic minorities who are homebound face additional challenges such as language barriers and lack of access to technology as compared to their white counterparts. 

Advancing to Digital Quality Measurement and the Use of Fast Healthcare Interoperability Resources (FHIR) in Physician Quality Programs—RFI 

AVAC appreciates the work of the Department of Health and Human Services to encourage and support the adoption of interoperable health information technology and to promote nationwide health information exchange to improve health care and patient access to their health information. Promoting the use of consistent patient data sets across health care settings can be vitally important to ensure quality patient care and health outcomes while reducing the reporting burden on providers. Additionally, timely and accurate reporting of immunization record data is also of great importance for public health disease surveillance and outbreak prevention activities. Consistent data collection and reporting is a foundational element for successful quality measurement, transparency, and accountability. 

AVAC fully supports greater use of electronic clinical quality measures (ecQMs) across health care programs managed by HHS, including the Centers for Medicare and Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), among other agencies. AVAC encourages CMS to look to existing ecQM resources that are available through the National Coordinator for Health Information Technology and as well as uniform data system modernization efforts within the Bureau of Primary Health Care at HRSA. Greater consistency in the adoption and use of electronic quality measures and a common reporting standard9 across HHS programs that serve vulnerable populations of all ages and across health care settings will improve overall quality of patient care, drive better health outcomes, as well as inform and empower patients, without creating additional complexity and reporting burdens on health care providers. 

In terms of vaccine data, AVAC supports incentivizing interoperable and bidirectional immunization data reporting to immunization information systems, leveraging tools and quality measures to improve health. As previously stated, provider, patient and caregiver access to immunization record data is essential to addressing health inequities in immunization coverage for the COVID-19, as well as the range of routinely recommended vaccines important to protecting the health and wellbeing of Medicare beneficiaries. 

Closing the Health Equity Gap in CMS Hospital Quality Programs— RFI 

AVAC appreciates the opportunity to respond to the request for information on closing the health equity gap included in the proposed rule and is grateful for CMS’ commitment to achieving equity in health care outcomes for Medicare beneficiaries. Even before the COVID-19 pandemic, vaccine preventable illness devastated the lives of thousands of adults each year, particularly older adults and those with underlying health conditions. Vaccine preventable conditions not only affect the patient but also their family members, caregivers and friends. Prior to the pandemic more than 50,000 adults died from vaccine-preventable diseases each year in the United States. While adult coverage has been persistently below Healthy People targets for most recommended vaccines, disparities in adult vaccination coverage rates are even more acute when broken down by age, race, ethnicity, socioeconomic status and geography. 

A recent examination of National Health Interview Survey data of adult immunization rates between 2010 and 2019 found persistent disparities of adult vaccination rates among racial and ethnic minority populations. According to the study, “Influenza vaccination coverage differed by race/ethnicity among adults aged ≥65 years (61.4% for Black, 63.9% for Hispanic, 71.9% for Asian, and 72.4% for White adults). Pneumococcal vaccine coverage in Black (57.7%), Hispanic (51.4%), and Asian (49.0%) individuals was lower than that in White (71.1%) individuals. Tdap and zoster vaccine coverage also differed by race/ethnicity.” Low household income and low education levels were also associated with lower immunization rates. 

Unfortunately, as result of the pandemic, routine vaccination rates, across all ages, have eroded further, leaving communities vulnerable to preventable disease, illness, and outbreaks. An analysis found that adult and adolescent CDC recommended vaccines declined between 41%-53% from March-August 2019 as compared to March-August 2020.11 Weekly vaccination rates among Medicare beneficiaries also declined drastically (70%–89% below 2019 rates) Long-standing health disparities are also laid bare in COVID-19 vaccination trends. Data indicate that 35% of Black Americans and 42% of Hispanic Americans report wanting to receive the COVID-19 vaccine compared to 53% of white Americans.12 Meanwhile, Black Americans and Hispanic Americans are proportionally receiving less COVID-19 vaccinations than their share of the total population. We are grateful for CMS’ recognition of and commitment to addressing systemic inequities that have resulted in poor health outcomes for certain populations. 

AVAC urges to CMS to promote dissemination and adoption of the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice including: 

  • Assess the vaccination status of patients at all clinical encounters, even among clinicians and other providers who do not stock vaccines. 
  • Identify vaccines patients need, then clearly recommend needed vaccines. 
  • Offer needed vaccines or refer patients to another provider for vaccination. 
  • Document vaccinations given, including in the jurisdiction’s IIS. 

This standard of practice for immunizations would ensure that Medicare beneficiaries have equitable access to information about recommended vaccines and the opportunity to receive those vaccines from a trusted health care provider Widespread implementation of the NVAC Standards for Adult Immunization Practice is also an important first step toward advancing the Healthy People 2030 developmental measure to increase the proportion of adults age 19 or older who get recommended vaccines (IID-D03).

Documenting vaccination through standardized EHR data collection can be relied upon for quality improvement activities. The COVID-19 pandemic has illustrated the need for investments in our nationwide immunization data framework, as well as the dissemination and adoption of federal guidelines and incentives to encourage consistent reporting and widespread utilization of immunizations across provider settings. In order to effectively identify and address health equity gaps and move toward meaningful quality improvement, there must be strong and clear criteria in place for data and quality reporting for providers that is supported by a strong foundation of baseline standards for interoperability, bidirectional exchange, data quality and security. 

AVAC encourages CMS to work with the HHS Office of Disease Prevention and Health Promotion to incorporate the Healthy People 2030 developmental measure, “Increase in the proportion of adults age 19 or older who get recommended vaccines (IID-003)” in its strategy to close equity gaps for adult immunization. Consistent assessment of immunization status through adoption of NVAC adult standards of care and implementation of adult immunization status measure are vital components to addressing longstanding disparities in access to immunization and will ensure that all Medicare beneficiaries receive a strong immunization recommendation from their provider, have the resources they need to make an informed decision and benefit from consistent access across providers to this important and lifesaving preventive service. 

AVAC supports the use of Quality Improvement Networks and Quality Improvement Organizations (QIN-QIOs) to address the core priority areas outlined in the CMS Equity Plan for Improving Quality in Medicare. The three priority areas which inform CMS policies and programs are: (1) Increasing understanding and awareness of health disparities; (2) developing and disseminating solutions to achieve health equity; and (3) implementing sustainable actions to achieve health equity.13 The QIN-QIOs have a demonstrated track record of success in testing and evaluating innovative and effective strategies for improving immunization coverage rates among targeted Medicare populations.14 AVAC encourages CMS to continue to utilize the QIN-QIOs for this purpose and urges CMS to include in the list of tasks outlined in future scopes of work (SOW) strategies to improve immunization coverage rates among hard to reach rural and geographically underserved areas as well as among disabled, homebound, inpatient and congregate care patient populations. 

Make the Immunization Registry Reporting a required measure under the Public Health and Clinical Data Exchange objective of the Promoting Interoperability performance category beginning with the performance period in CY 2022 

Robust immunization record data reporting will empower providers, patients, and caregivers to make educated decisions about vaccinations, reduce missed opportunities for immunization and minimize the likelihood of overvaccination, and help inform health care system efforts to close health equity gaps and prevent disease outbreaks. AVAC supports the proposal included in the proposed rule that would make the Immunization Registry Reporting a required measure under the Public Health and Clinical Data Exchange objective of the Promoting Interoperability performance category beginning with the performance period in CY 2022. 

However, we are concerned about the burden this proposal may impose on physicians and other clinicians if it is finalized without additional improvements. Reporting to the IIS is burdensome for some providers because it is not well integrated into EHRs and clinical workflows. State IIS systems lack interoperability and often cannot properly receive and transmit data from physician practices and other vaccine providers. They should not be penalized for these barriers that are out of their control. CMS should work with ONC to reduce the burden of reporting to IIS at the point of care. We share the agency’s view that more consistent immunization data reporting is “critical for understanding vaccination coverage both at the jurisdiction level and nationwide and identifying where additional vaccination efforts are needed.” Health information technology plays a vital role in the identification of disease outbreaks, implementation of response efforts, and identification of gaps in health care delivery across the health care system. Similarly, vaccines play a key role in combatting the COVID-19 global pandemic, as well as protecting against a range of other potentially devastating, yet avoidable, infectious conditions. The COVID-19 pandemic has also demonstrated that Immunization Information Systems (IIS) are a foundational element of our public health and health care infrastructure. 

Over the past several years, incentive programs like Meaningful Use (MU) and Promoting Interoperability (PI) have helped to accelerate electronic IIS reporting and have improved Electronic Health Record (EHR)-IIS interoperability and increased the value and broad use of IIS data. According to the Office of the National Coordinator for Health Information Technology (ONC), the MU program has resulted in an increase in the percentage of Medicare providers report immunization record data to an IIS from 51% in 2011 to 72% in 2014. 

As CMS evaluates this proposal, AVAC urges CMS to consider the crucial role that IIS’ play in improving vaccination at the point of care, at the population health level, and to help address the health disparities which have only worsened during the pandemic. Requiring the Immunization Registry Reporting measure could: 1) increase reporting of immunization data into a centralized jurisdiction-based system which would enhance patient data completeness and quality in IIS, 2) facilitate better inter- and intra-state data sharing between other IIS, health systems, and other HIT systems, and 3) improve vaccination uptake and health equity by determining areas of under vaccination. 

AVAC urges CMS to work with ONC to address the burden for providers of consistently reporting to and querying the IIS by integrating it into EHRs and improving usability. As CMS moves forward with this proposal in the final rule, AVAC also strongly encourages the agency 

to consider adding financial incentives and support programs for small and midsize providers who might need additional assistance with establishing an EHR-IIS interface. In certain circumstances, exceptions might continue to be necessary for some providers. 

Immunizations are an important public health imperative and ensuring that immunization providers are properly reimbursed and have access to tools and resources to be efficient and effective is key to fostering a sustained environment of timely immunization. Vaccine services administered by health care providers, at the point of care, is an ecosystem that needs to be maintained, supported, and encouraged. 

We appreciate this opportunity to share our perspective on the proposed rule and are grateful for your work to improve data reporting and quality improvement measurement tools. Please contact an AVAC Coalition Manager at (202) 540-1070 or info@adultvaccinesnow.org if you wish to further discuss our comments. To learn more about the work of AVAC visit www.adultvaccinesnow.org. 

Sincerely, 

Alliance for Aging Research 

American Immunization Registry Association (AIRA) 

American Pharmacists Association 

Asian Pacific Islander American Health Forum 

Association of Immunization Managers 

BIO 

Dynavax 

Families Fighting Flu 

GSK 

Hepatitis B Foundation 

Hep B United 

Infectious Diseases Society of America (IDSA) 

Immunization Action Coalition 

Immunization Coalition of Washington DC 

Medicago 

Merck & Co Inc. 

National Association of County and City Health Officials 

National Association of Nutrition and Aging Services Programs 

National Black Nurses Association 

National Consumers League 

National Foundation for Infectious Diseases 

National Hispanic Medical Association 

Novavax 

Pfizer 

Sanofi 

Seqirus 

STChealth 

The Gerontological Society of America 

Trust for America’s Health 

Vaccinate Your Family 

Vaxcare 

AVAC Provides Comments on OMB’s Request for Information

On August 6, AVAC offered comments to the Office of Management and Budget’s Request for Information: Methods and Leading Practices for Advancing Equity and Support for Underserved Communities Through Government. AVAC commented in response to 4 of OMB’s specific areas: Area 1: Holistic and program- or policy-specific assessments of equity for public sector entities; Area 2: Remedying barriers, burdens, and inequities in public service delivery access; Area 4: Assessing equity in procurement and contracting processes; and Area 5: Accessible and meaningful agency engagement with underserved communities. 

Dear Deputy Director Young,

The Adult Vaccine Access Coalition (AVAC) welcomes the opportunity to respond to the Request for Information posed by the Office of Management and Budget (OMB). We recognize the importance of equitable access to health care and are committed to far-reaching policies, programs, and partnerships that increase equitable service delivery.

AVAC consists of over 60 organizational leaders in health and public health that are committed to driving federal policy changes that will strengthen and enhance access to adult vaccines and awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions through 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.

Even before the COVID-19 pandemic, vaccine preventable illness devastated the lives of thousands of adults each year, particularly older adults and those with underlying health conditions. Vaccine preventable conditions not only affect the patient but also their family members, caregivers and friends. Despite the well-known benefits of immunizations, more than 50,000 adults die from vaccine-preventable diseases while adult coverage has lagged Healthy People targets for most commonly recommended vaccines. Disparities in adult vaccination coverage rates are even more acute when broken down by age, race, ethnicity, socioeconomic status and geography.

The COVID-19 pandemic has brought these inequities to the forefront, with the CDC reporting as of June 7, that of the 57% of recipients disclosing their ethnicity when receiving their COVID-19 vaccine, 61% were White, 9% were Black, 15% were Hispanic, and 6% were Asian. The relatively low representation of ethnic minorities among COVID-19 vaccine recipients is the most recent example of disparities in vaccination coverage across socio-economic strata. While the pandemic has brought attention to these disparities, the unfortunate reality is that they are not new. Inequities in vaccination rates of minority communities are seen across numerous preventive vaccines. Further, lack of access to care sites has contributed to lower immunization rates in rural compared to urban areas. The impact of immunization on population health is well known, and ensuring that all populations, including the most vulnerable, have access to vaccination is a critical step in ensuring equitable primary health care.

OMB has requested comments on “methods for assessing whether agency policies and actions (e.g., programs, services, processes, and operations) equitably serve all eligible individuals and communities, particularly those that are currently and historically underserved”. AVAC has provided comments in response to 4 of OMB’s specific areas of feedback in greater detail below:

  • Area 1: Holistic and program- or policy-specific assessments of equity for public sector entities;
  • Area 2: Remedying barriers, burdens, and inequities in public service delivery access;
  • Area 4: Assessing equity in procurement and contracting processes;
  • Area 5: Accessible and meaningful agency engagement with underserved communities.

Area 1: Holistic and program- or policy-specific assessments of equity for public sector entities

To ensure equity in all public sector policies and programs, thorough assessment is required to identify areas of weakness and monitor the progress of proposed solutions. To conduct such assessments, it is critical to have robust monitoring infrastructure, committees, and processes in place. To this end, AVAC suggests the following steps to assess equity in access to vaccinations:

  • Assess equity in vaccination rates among beneficiaries of public insurance programs to understand areas of inequity that can be addressed through policy changes. Currently, over a quarter of the U.S. population relies on a public program for health coverage, and thus the government represents a significant access point for preventive services. In 2016, immunization rates for Medicaid beneficiaries were up to 12% lower than for commercially insured patients. Inequalities of immunization access persist for our nation’s most vulnerable population that will require additional investigation to properly assess and address.
  • Invest in improving Immunization Information Systems (“IIS”) to more effectively track and assess inequities in immunization uptake. The CDC and other public health stakeholders must compile vaccination records from a range of IIS across states and jurisdictions in order to depict a comprehensive picture of vaccine coverage and uptake. AVAC strongly supports modernizing and strengthening the capabilities of IIS to capture and share vaccination information in a uniform way. Robust IIS data capture and reporting are critical to understanding patterns in vaccination rates, including disparities by race, socioeconomic status, insurance type, and/or region that perpetuate health inequities.
  • Encouraging the COVID-19 Health Equity Task Force to transition into a permanent task force that includes a focus on vaccination. This multi-agency and multi-disciplinary Task Force was established to provide specific recommendations to the Administration for mitigating inequities caused or exacerbated by the pandemic. It continues to be essential that all communities have equitable access to COVID-19 vaccinations and booster shots. It is also critical that individuals get caught-up on routine and recommended vaccinations, particularly as students return to in person learning, adults return to the workplace, and people of all ages begin socializing in groups. We recommend that this Task Force continue its work, with an additional goal of on recovering and sustaining high vaccination rates for all vaccines.

Area 2: Remedying barriers, burdens, and inequities in public service delivery access

Multiple barriers to vaccine access remain in the US and disproportionately affect low-income populations who rely on public programs and coverage through Medicare, Medicaid, and those with subsidized commercial insurance. Systemically addressing barriers to vaccine access and promoting culturally competent service delivery can generate vaccine acceptance and demand among at-risk and underserved communities and, ultimately, better protect them against vaccine-preventable diseases. AVAC urges OMB to consider the following steps to address the barriers to vaccine access that perpetuate health inequities:

  • Utilize health literacy reviews of all vaccine-related information released by the Administration to ensure information is accessible. The Administration routinely publishes critical vaccine-related information. Oftentimes these materials are not written in a reader-centered manner, leading to a lack of understanding among patients and potential missed vaccination opportunities. There is an outstanding need to ensure that all patients can access and understand the policies and requirements that impact their access to healthcare. To that end, we recommend implementing health literacy reviews for all vaccine-related information released by the Administration to ensure that published material is reader-centered and easily understood.

Area 4: Assessing equity in the administration of agency grant programs and other forms of financial assistance

Grant programs and other forms of financial assistance are critical to immunization service delivery and present an important means to promote equitable access and uptake of vaccination. It is critical that immunization-related grant programs both promote vaccine equity and are administered equitably. AVAC recommends the following process changes to promote immunization equity via public sector grant programs and financial assistance:

Conduct a systematic review of all grants that use or could incorporate vaccine equity. The American Rescue Plan and Coronavirus Response and Relief Supplemental Appropriations Act direct funds to promoting COVID-19 vaccine access, acceptance, and uptake among racial and ethnic minority communities. Despite these efforts, vaccination uptake in some communities remains lower than others, suggesting a need for sustained outreach. Future ARP related immunization grants issued should be prioritized based on their ability to successfully promote vaccination to underserved communities. This assessment should be made public so that best practices can be implemented across the country.

Area 5: Accessible and meaningful agency engagement with underserved communities

Achieving equity in immunization access and uptake requires a thorough understanding of the unique needs and access barriers experienced by at-risk and underserved communities. This understanding can only be gained through direct engagement. It then must be applied to create culturally competent, tailored solutions that meet communities’ specific needs. AVAC recommends the following community engagement initiatives:

  • Engage community-based organizations to identify policy changes that can improve access and uptake of vaccinations. To ensure representation of community voices in the National Vaccine Program planning and execution processes, AVAC recommends the establishment of a community advisory subcommittee that could be formed under the National Vaccine Advisory Committee (NVAC). This advisory group consisting of representatives from community-based organizations could be directed to review and recommend additional vaccine equity goals for federally supported immunization programs, review progress toward those goals, and recommend policy changes to improve equity in access and uptake.

We appreciate the opportunity to provide our perspective on the federal government’s methods to equitably reach all eligible individuals with life-saving vaccines. We would be happy to answer any questions or provide additional information. Please contact an AVAC manager.

AIRA
Alliance for Aging Research
American Lung Association
Association of Asian Pacific Community Health Organizations (AAPCHO)
GSK
Immunization Action Coalition
March of Dimes
Merck
National Viral Hepatitis Roundtable
STChealth
The Gerontological Society of America
Trust for America’s Health

AVAC Provides Feedback for the Development of 21st Century CURES 2.0

AVAC sent a letter to Reps DeGette and Upton with recommendations on the 21st Century CURES 2.0 Act that is currently under development. In the letter, AVAC urges for the inclusion of multiple items, such as making vaccine regulatory flexibilities and authorities granted during the public health emergency permanent and increasing resources available to vaccine and immunization programs.

To Representatives DeGette and Upton:

The Adult Vaccine Access Coalition (AVAC) appreciates the opportunity to provide feedback that will help shape and inform the development of 21st Century Cures 2.0. We greatly appreciate your years of leadership in federal policymaking aimed at accelerating innovations in clinical research and trials as well as improving processes that will expediate access to breakthrough therapies, treatments, and technologies. We are also grateful that your draft legislation calls attention to the public health challenges that have become apparent over the course of the COVID-19 pandemic and offers some meaningful solutions.

AVAC consists of over 60 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 to and utilization of adult immunizations.

As you know, immunizations are a highly cost-effective form of preventive medicine that help save lives by protecting the health and wellbeing of individuals and families in communities nationwide. Over the last decade, advancements in technology, policy, and infrastructure have strengthened the immunization landscape. However, the COVID-19 pandemic put a tremendous strain on our chronically underfunded public health infrastructure and exposed important weaknesses that simply must be addressed. We must apply the lessons learned and integrate best practices as we work together to ensure the tools and capabilities necessary to swiftly and confidently respond to future disease outbreaks, pandemics, or disasters are in place.

Section 104. Vaccine and Immunization Programs: We are incredibly grateful that the CURES 2.0 Act recognizes the need for additional resources to bolster immunization awareness efforts and infrastructure.  Specifically, the draft authorizes $25 million for an awareness campaign to educate the public with respect to the safety and importance of vaccines and an additional $25 million to strengthen immunization infrastructure systems (IIS). These resources for vitally important to the long-term success of COVID-19 vaccination efforts as well as routine immunization catch up activities that are necessary preserve and protect the health of individuals, families and entire communities.

AVAC urges you to consider also incorporating provisions included in bipartisan legislation, theImmunization Infrastructure Modernization Act (HR550).

While most health departments have immunization infrastructure in place, we learned during the pandemic that the data collection and reporting capabilities of these systems varied greatly. We must ensure that Immunization Information systems (IIS) can meet certain basic security, data collection and reporting standards if we are going to be able to have real-time reporting of reliable immunization information during the next disease outbreak or pandemic.

In addition to funding, Congress has an important leadership role to play in advancing a federal policy framework to help guide IIS modernization investments in terms of the capacity and breadth of these systems, as well as establishing clear goals, expectations and outcomes. As Congress continues to make investments in immunization information system modernization efforts, ensuring these systems can be relied upon to consistently collect and report accurate immunization record data securely and in real-time is essential not only for the next pandemic but also for routine immunization activities.

IIS are computerized, multi-faceted systems that operate in 62 jurisdictions, and have the ability to maintain immunization records across the lifespan. They can be used by providers to order vaccines and track inventory, view a patient’s vaccine history to ensure they are fully vaccinated but not over-vaccinated, remind patients when they are due to receive a recommended vaccine, and, at a population level, track coverage and identify areas where there are low immunization rates so public health programs can develop targeted immunization efforts in response.

However, the pandemic laid bare the fact that IIS capabilities vary across states and many systems were in woefully need of modernization to adequately meet the challenges of a COVID-19 mass vaccination campaign. These systems are vital to public health efforts to track coverage and identify areas where there are low immunization rates so targeted immunization outreach and education efforts can be developed in response. Without investments in immunization infrastructure – IIS in particular – the racial and geographic disparities in vaccination take-up rates are hard to track and address.

We ask that you look to the framework set out in the “IIS Modernization Act, H.R. 5502” for added guidance on how to enhance systems to manage both routine immunization efforts and outbreaks of other vaccine preventable diseases. Among other things, the bill includes the following provisions:

  • An assessment of current capabilities and gaps among immunization providers;
  • Expand enrollment and training of immunization providers;
  • Support real-time immunization record data exchange and reporting;
  • Improve secure data collection, transmission, bidirectional exchange, maintenance, and analysis of immunization information;
  • Enhance security of bidirectional exchange of immunization record data and interoperability of immunization information systems with health information technology platforms; and
  • Enhance data exchange interoperability with other jurisdictions.

Section 402. Strategies to Increase Access to Telehealth under Medicaid and Children’s Health Insurance Program and Section 403. Extending Medicare Telehealth Flexibilities.

The CURES 2.0 Act takes important steps to advance policies to integrate telehealth into public health insurance programs. The provisions affirm the use of telehealth services and enable opportunities for additional health care providers and sites to utilize telehealth services in the provision of care. The COVID-19 pandemic accelerated the adoption of telehealth services and provided access to care at a time when in person visits were not possible. AVAC appreciates that your legislation seeks to preserve and expand upon the availability of telehealth services and the many flexibilities that were granted as a result of the public health emergency.

In terms of immunization, AVAC believes that telehealth services can be a valuable tool for primary care providers to conduct patient immunization status assessments and counseling, particularly for complex patients with chronic conditions. Allowing providers to utilize telemedicine to conduct patient outreach, counseling and education on the importance of recommended vaccines not only during pandemics and public health emergencies but also during the course of regular care will help drive improvements in immunization rates across the lifecourse. Emphasizing support for the provision of telehealth services by providers who care for underserved populations will also enable them to improve and expand immunization efforts within their practices.

Additionally, AVAC supports making vaccine regulatory flexibilities and authorities granted during the public health emergency permanent. Allowing for a wide diversity of health care providers and sites of care to offer vaccines enabled rapid deployment of COVID-19 vaccines to millions of Americans. AVAC urges you to consider including policies that created more access points across communities for immunization and assured health care providers that they would be compensated for vaccine services. We hope Congress will work to extend them beyond the pandemic and to routinely recommended vaccines. Inclusion in the CURES 2.0 Act would be an important step toward that goal.

AVAC appreciates your work and leadership on this important legislation and your consideration of our recommendations. We look forward to working with you throughout the legislative process and stand ready to serve as a resource as you advance this important bipartisan bill.

 

 

 

AVAC Offers Comments on Medicare Program; Hospital Prospective Payment Systems and Quality Programs and Medicare Promoting Interoperability Program Requirements

AVAC sent a letter to the Centers for Medicare & Medicaid Services offering comments on the Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2022 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals.

To Whom It May Concern: 

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2022 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; 

Specifically, AVAC wishes to highlight its strong support for the following proposals included in this proposed rulemaking: 

  • Adoption of a COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure beginning With the FY 2023 Hospital IQR program/PCHQR program/LTCHQR program 
  • Maintaining the Influenza Vaccination Coverage Among Healthcare Personnel in the FY23 Hospital IQR Program/PCHQR program/LTCHQR program 
  • Advancing Health Information Exchange through the development of quality measures and implementation of interoperability standards that will facilitate and improve immunization record reporting and real-time information sharing across health care providers, facilities and public health. 
  • Efforts to close the Health Equity Gap and the opportunity to offer our views on important actions that are necessary to address longstanding disparities in adult immunization rates among minority and underserved populations. 

AVAC consists of over 60 organizational leaders in health and public health that are committed to driving federal policy changes that will strengthen and enhance access to adult vaccines and awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions through 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. 

COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure 

AVAC appreciates the opportunity to express its strong support for CMS’ proposal to add a new COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure to the FY 2023 Hospital Inpatient Quality Reporting (IQR) Program. The COVID-19 pandemic had a disproportionate and devastating impact on older adults living in long-term care and congregate care settings. This new measure would require hospitals to report on COVID-19 HCP vaccination rates over a shortened period in order to assess whether hospitals are taking steps to limit the spread of COVID-19 among their HCP, reduce the risk of transmission within their facilities and help sustain the ability of hospitals to continue serving their communities throughout the COVID-19 PHE and beyond. Under this proposal, hospitals would report the vaccination data through the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN) beginning October 1, 2021 through December 31, 2021. 

AVAC believes this measure is vitally important to protect the health and wellbeing of our community, particularly older adults. Reporting of the COVID-19 for HCP measure through the NHSN will help ensure transparency and accountability in community infection prevention and control efforts and is consistent with other HCP vaccination measures intended to preserve health and mitigate infectious disease outbreaks in the inpatient hospital setting. 

We know from reporting of influenza vaccination coverage of HCPs that provider uptake of the vaccine is also associated with that provider recommending vaccination to patients and encourages greater patient vaccination uptake. HCP vaccination can also potentially reduce illness-related missed work and disruptions to patient care. Lastly, reporting of HCP vaccination rates helps inform patients and caregiver choice when considering facilities from which to seek care, particularly for those at high-risk for developing serious complications from COVID–19. While data on the effectiveness of COVID–19 vaccines to prevent asymptomatic infection or transmission is limited, AVAC believes the COVID-19 HCP vaccination measure should nonetheless be included as part of efforts to assess and reduce the risk of transmission of COVID–19 within hospitals and urges CMS to maintain this proposal in the final rule. 

The proposed rule includes a shortened reporting period of October through December 2021. AVAC supports the proposed timeframe and appreciates that the COVID-19 HCP reporting period and measure specifications align closely with the Influenza HCP vaccination measure (NQF 0431). 

Maintaining the Influenza Vaccination Coverage Among Healthcare Personnel in the FY23 Hospital IQR Program PPS-exempt Cancer Hospital Quality Reporting Program/ Long-term Care Hospitals Quality Reporting Program (LTCHQRP). 

AVAC also strongly supports the proposal to maintain the Influenza Vaccination Coverage Among Healthcare Personnel (NQF#0431). This measure plays a critical role in the CMS Quality Strategy as well as the National Quality Strategy in terms of influenza immunization efforts. Ensuring healthcare personnel vaccination adherence against influenza has been shown to improve patient safety and reduce disease transmission, which is essential for immunocompromised patients in the cancer hospital setting. 

Empowering patients and caregivers with the ability to assess cancer hospitals based on this measure could ultimately result in improved outcomes for patients through lower complications. Data transparency of reported measures is an important tool for patients and 

families seeking to evaluate LTCH settings and an essential component in the identification and management of influenza outbreaks. We support public reporting LTCH QRP data on a CMS website, such as Hospital Compare and support the inclusion of the two above measures in this effort. Tracking vaccine status among health care workers has the ability to increase vaccination rates and reduce absenteeism among healthcare personnel. 

Fast Healthcare Interoperability Resources (FHIR) in support of Digital Quality Measurement in Quality Reporting Programs – RFI 

AVAC appreciates the work of the Department of Health and Human Services to “encourage and support the adoption of interoperable health information technology and to promote nationwide health information exchange to improve health care and patient access to their health information.” Promoting the use of consistent patient data sets across health care settings can be vitally important to ensure quality patient care and health outcomes while reducing the reporting burden on providers. Additionally, timely and accurate reporting of immunization record data is also of great importance for public health disease surveillance and outbreak prevention activities. Consistent data collection and reporting is a foundational element for successful quality measurement, transparency, and accountability. 

AVAC fully supports greater use of electronic clinical quality measures (ecQMs) across health care programs managed by HHS, including the Centers for Medicare and Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), among other agencies. As CMS seeks feedback on definitions for digital quality measures (dQMs) for the Hospital IQR Program, we would encourage CMS to look to existing ecQM resources that are available through the National Coordinator for Health Information Technology6 and as well as uniform data system modernization efforts within the Bureau of Primary Health Care at HRSA. Greater consistency in the adoption and use of electronic quality measures and a common reporting standard8across HHS programs that serve vulnerable populations of all ages and across health care settings will improve overall quality of patient care, drive better health outcomes, as well as inform and empower patients, without creating an additional complexities and reporting burdens on health care providers. 

In terms of vaccine data for patients in hospital settings, AVAC supports incentivizing interoperable and bidirectional immunization data reporting to immunization information systems, leveraging tools and measures through the hospital IQR program. As previously stated, provider, patient and caregiver access to immunization record data is essential to addressing health inequities in immunization coverage for the COVID-19, as well as the range of routinely recommended vaccines important to protecting the health and wellbeing of Medicare beneficiaries in inpatient care settings. 

Quality measurement programs through Medicare play a critical role in promoting improved quality and encouraging adherence to and consistent utilization of recommended health care interventions, including adult vaccines. Vaccines play a vital role in preventing illness and death, reducing caregiving demands, avoiding unnecessary healthcare spending, and setting the foundation for healthy aging. 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 across the lifecourse, especially given the COVID-19 pandemic and annual flu seasons. 

Closing the Health Equity Gap in CMS Hospital Quality Programs— Request for Information – RFI 

AVAC appreciates the opportunity to respond to the request for information on closing the health equity gap included in the proposed rule. Even before the COVID-19 pandemic, vaccine preventable illness devastated the lives of thousands of adults each year, particularly older adults and those with underlying health conditions. Vaccine preventable conditions not only affect the patient but also their family members, caregivers and friends. Prior to the pandemic more than 50,000 adults died from vaccine-preventable diseases each year in the United States. While adult coverage has lagged behind Healthy People targets for most commonly recommended vaccines. Disparities in adult vaccination coverage rates are even more acute when broken down by age, race, ethnicity, socioeconomic status and geography. 

Unfortunately, as result of the pandemic, routine vaccination rates, across all ages, have eroded further, leaving communities vulnerable to preventable disease, illness, and outbreaks. An analysis found that adult and adolescent CDC recommended vaccines declined between 41%-53% from March-August 2019 as compared to March-August 2020.1 Weekly vaccination rates among Medicare beneficiaries also declined drastically (70%–89% below 2019 rates) Long-standing health disparities are also laid bare in these trends. Further, data indicate that 35% of Black Americans and 42% of Hispanic Americans report wanting to receive the COVID-19 vaccine compared to 53% of white Americans.2 Meanwhile, Black Americans and Hispanic Americans are proportionally receiving less COVID-19 vaccinations than their share of the total population. These trends could have serious consequences for the future, threatening widespread outbreaks of vaccine preventable conditions. We are grateful for CMS’ commitment to addressing systemic inequities that have resulted in poor health outcomes for certain populations. 

AVAC urges CMS to promote dissemination and adoption of the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice1. This standard of practice for immunizations would ensure that Medicare beneficiaries have equitable access to information about recommended vaccines and the opportunity to receive those vaccines from a trusted health care provider. Consistent assessment of immunization status through adoption of NVAC adult standards of care and implementation of adult immunization status measure are vital components to addressing longstanding disparities in access to immunization and will ensure that all Medicare beneficiaries receive a strong immunization recommendation from their provider and have the resources they need to make an informed decision. Widespread implementation of the NVAC Standards for Adult Immunization Practice is also an important first step toward advancing the Healthy People 2030 developmental measure to increase the proportion of adults age 19 or older who get recommended vaccines (IID-D03).

Another important element to closing the equity gap is consistent data collection and real-time reporting. The COVID-19 pandemic has illustrated the need for investments in our nationwide immunization data framework, as well as the dissemination and adoption of federal guidelines and incentives to encourage consistent reporting and widespread utilization of immunization information systems (IIS) across provider settings. In order to effectively identify and address health equity gaps, there must be strong and clear criteria in place for data reporting elements, provider usage, along with baseline standards 

interoperability, bidirectional exchange, data quality and security. AVAC encourages CMS to work with the HHS Office of Disease Prevention and Health Promotion to include the Healthy People 2030 developmental goal to increase the proportion of people with vaccine records in an IIS in its strategy to close equity gaps for adult immunization. Robust immunization record data reporting will empower providers, patients and caregivers to make educated decisions about vaccinations, reduce missed opportunities for immunization and minimize the likelihood of overvaccination, and help inform health care system efforts to close health equity gaps and prevent disease outbreaks. 

Lastly, AVAC also expresses support for the use of Quality Improvement Networks and Quality Improvement Organizations (QIN-QIOs) as a means to address the core priority areas outlined in the CMS Equity Plan for Improving Quality in Medicare. The three priority areas which inform CMS policies and programs are: (1) Increasing understanding and awareness of health disparities; (2) developing and disseminating solutions to achieve health equity; and (3) implementing sustainable actions to achieve health equity. The QIN-QIOs have a demonstrated track record of success in testing and evaluating innovative and effective strategies for improving immunization coverage rates among targeted Medicare populations.5 AVAC encourages CMS to continue to utilize the QIN-QIOs for this purpose and urges CMS to include in the list of tasks outlined in future scopes of work (SOW) strategies to improve immunization coverage rates among hard to reach rural and geographically underserved areas as well as among disabled, homebound, inpatient and congregate care patient populations. 

Thank you again for the opportunity to share our perspective on this proposed rule. Please contact an AVAC Coalition Manager at (202) 540-1070 or lfoster@adultvaccinesnow.org if you wish to further discuss our comments. To learn more about the work of AVAC visit www.adultvaccinesnow.org. 

Sincerely, 

AIRA 
Alliance for Aging Research 
Association of Asian Pacific Community Health Organizations (AAPCHO) 
GSK 
Immunization Action Coalition 
Infectious Diseases Society of America 
Kimberly Coffey Foundation 
National Foundation for Infectious Diseases 
Sanofi 
Seqirus 
STChealth 
The AIDS Institute 
The Gerontological Society of America 
Trust for America’s Health 
Vaccinate Your Family