AVAC Comment Letter Encourages CMS to Move Forward with Adult Immunization Quality Measures Under New Home Health Value-Based Purchasing Model (HHVBP)

AVAC sent CMS comments on the CY 2016 Home Health Payment proposed rule, commending them for the inclusion of several adult immunization measures including the Influenza Immunization Received for Current Flu Season (NQF#0522) and for considering two new immunization process measures relating to influeza and shingles for study and inclusion in the HHVBP. AVAC also asked that CMS consider including an alternative measure for the Pneumococcal Polysaccharide Vaccine Ever Received (NQF#0525), such as Pneumonia Vaccination Status for Older Adults (NQF#0043), in the final rule because this measure no longer reflects current recommendations of the Advisory Committee on Immunization Practices (ACIP).

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the CY 2016 CMS Home Health Payment Proposed Rule.

AVAC consists of more than 35 organizational leaders in health and public health that are committed to tackling 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 mission is informed by a growing body of 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 as a whole.

AVAC 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 measures to encourage health plans to track, report and achieve increased adult immunization rates.

AVAC commends CMS for including the Influenza Immunization Received for Current Flu Season (NQF#0522) and among the Population/Community Health measures proposed for adoption in the Home Health Value-Based Purchasing Model (HHVBP).  We also appreciate that the proposed rule includes a Pneumococcal Polysaccharide Vaccine Ever Received (NQF#0525) but would note this measure no longer reflects current recommendations of the Advisory Committee on Immunization Practices (ACIP).  AVAC urges CMS to consider including an alternative measure, such as Pneumonia Vaccination Status for Older Adults (NQF#0043) in the final rule.

These two measures represent an important baseline for access to influenza and pneumococcal vaccination services and are being utilized effectively in other settings under the Medicare program. We believe they will greatly enhance the ability of home health providers to monitor immunization status and report offered and administered influenza and pneumococcal immunizations to beneficiaries. Reducing the number of missed immunization opportunities among patients in the home health setting is critical to improving health and reducing the burden of vaccine preventable disease.

Looking ahead, we could note that the NQF report “Priority Setting for Healthcare Performance Measurement: Addressing Performance Measure Gaps for Adult Immunizations.”1 noted that 60 measures have been developed to address pneumococcal immunization and that to reduce the burden and improve the value of measurement, measures should be harmonized and consolidated and “at a minimum, all measures should be up to date with current ACIP/CDC recommendations.” To that goal, through its Health and Well-Being Standing Committee, NQF has proposed and approved standard specifications for pneumococcal vaccination to enable measure stewards for the existing measures (CMS and NCQA) to assess, and presumably modify, measures based on the revised standardized specifications.2

We encourage CMS to work with relevant stakeholders and quality measure organizations such as NQF to develop an updated pneumococcal immunization measure that reflects the current Advisory Committee for Immunization Practice (ACIP) recommendation for PCV13 and PPSV23 vaccination in adults age 65 and older as well as at risk adults 19-64 years old for inclusion in the HHVBP.

AVAC is also pleased that CMS is considering two new immunization process measures for study and inclusion in the HHVBP, Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431) and Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination?”.  As the proposed rule notes, NQF#0431 is already being utilized in a number of other health care settings.

Moreover, leading medical and health professional associations support influenza vaccination policies for healthcare professionals to help protect patients.3 Healthcare personnel are the first line of defense when it comes to preventing illness and preserving health.  Measurement tools reflecting this priority are essential to promoting health and advancing prevention in the home health setting and AVAC strongly supports the inclusion of this measure in the final rule.

We greatly appreciate that CMS is also seeking to make herpes zoster vaccination a priority for the HHVBP.  As the proposed rule notes, only 24.2 percent of adults age 60 and older reported receiving the herpes zoster vaccine, which falls short of the modest Healthy People 2020 target rate of 30 percent.4  The health and economic burden associated with shingles and its complications are significant. We commend CMS for recognizing that, “receiving the vaccine will often reduce the course and severity of the disease”.  In 2007, the Agency for Healthcare Research and Quality (AHRQ) estimated the average cost of shingles and its complications to be $566 million a year while another study estimated the overall cost could be as high as $1.7 billion a year. The disease also takes a toll on the health and quality of life of those who have been afflicted.  Postherpetic neuralgia (PHN) is the most common complication; however, other lingering and potentially severe complications and pain can impact an individual for months.

AVAC urges CMS to maintain the herpes zoster vaccination process measure in the final rule and we hope that other value-based purchasing and quality reporting programs will consider this measure in the future, particularly since the absence of zoster vaccination measures has been identified by the National Quality Forum as a significant gap in performance measurement and the development of a measure has recently been identified as a priority.

Thank you for the opportunity to offer our perspective on this proposed rule.  Please contact the AVAC Coalition Manager at (202) 540-1070 or info@adultvaccinesnow.org if you wish to discuss our comments or adult immunization issues.


American Association of Occupational Health Nurses

American College of Preventive Medicine

Asian & Pacific Islander American Health Forum


Gerontological Society of America

Immunization Action Coalition

Infectious Diseases Society of America

National Association of County and City Health Officials

National Foundation for Infectious Diseases



Trust for America’s Health