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.
- 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 email@example.com if you wish to further discuss our comments. To learn more about the work of AVAC visit www.adultvaccinesnow.org.
Alliance for Aging Research
American Immunization Registry Association (AIRA)
American Pharmacists Association
Asian Pacific Islander American Health Forum
Association of Immunization Managers
Families Fighting Flu
Hepatitis B Foundation
Hep B United
Infectious Diseases Society of America (IDSA)
Immunization Action Coalition
Immunization Coalition of Washington DC
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
The Gerontological Society of America
Trust for America’s Health
Vaccinate Your Family