October 5, 2020
Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 8016
Baltimore, MD 21244-8016
RE: CMS-1734-P Medicare Program: CY 2021 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; etc.
To Whom It May Concern:
As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on Medicare Program: Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; etc.
- Strongly supports the proposed increase in practice expense relative value units for Vaccine Administration and urges the Centers for Medicare and Medicaid Services (CMS) to implement the increase prior to the January 1, 2021 effective date for the PFS rule.
- Supports the inclusion of recommended immunizations in the written screening schedule developed for beneficiaries through the Annual Wellness Visit (AWV) as well as information about vaccines designed for older adults.
- Supports the engagement in bi-directional exchange on immunization data through Health Information Exchange (HIE) through the establishment of a new alternative reporting measure: Health Information Exchange (HIE) Bi-Directional Exchange.
- Support maintaining adult immunization quality measures throughout specialty measure sets (Appendix 1, Table B)
AVAC consists of sixty organizational leaders in health and public health that are committed to addressing the range of barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our priorities and objectives are driven by a consensus process with the goal of enabling the range of stakeholders to have a voice in the effort to improve access and utilization of adult immunizations.
Despite the well-known benefits of immunizations, more than 50,000 adults die from vaccine-preventable diseases while adult coverage lags behind federal targets for most commonly recommended vaccines: influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, and HPV.5,6 One of our key coalition priorities is to advocate for federal benchmarks and quality measures to encourage improved tracking and reporting of adult immunization status that will result in increased adult immunization rates.
Proposed Increase in Vaccine Administration Rates
AVAC is grateful for CMS’ ongoing work to restore vaccine administration rates. As you may recall from our comments to the 2020 proposed rule, we raised concern about the proposed 15% reduction in the reimbursement rate for CPT codes for vaccine administration (90471-90474). If the proposed reductions had taken effect, they would have resulted in a cumulative 44 percent reduction in reimbursement over a three-year period.
Thankfully, the Administration acted to stop the proposed reduction in the final rule, stating, “We recognize that it is in the public interest to ensure appropriate payments to physicians and other practitioners for provision of the immunization administration services that are used to deliver vaccines and plan to review the valuations for these services to ensure appropriate payment.”
CMS has demonstrated its’ commitment to ensuring that providers receive adequate reimbursement for the costs associated with vaccine administration. Specifically, the 2021 proposed rule seeks to crosswalk the 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).
We appreciate that CMS has agreed to move forward with a proposal that would decouple the practice expense RVU for vaccine administration from therapeutic injection (96372), which caused the decline in rates over the past several years. We share CMS’ view that that the crosswalk with CPT code 36000 “is the most accurate valuation of these services and will also serve to ensure the appropriate relative resources involved in furnishing all of these services is reflected in the payment for these critical immunization and vaccination services in the context of the health needs of Medicare beneficiaries.”
AVAC shares the agency’s desire to promote beneficiary access to vaccines in the context of the COVID-19 Public Health Emergency, and greatly appreciates that action is being taken to address stakeholder concerns regarding past reductions in payment rates for vaccine administration services.
As you know, there has been a significant reduction in routine immunizations across the life course due to COVID. While practices are starting to rebound in terms of patient visits, they have not been fully rebounding in terms immunization delivery.
CMS recognizes that adequate reimbursement for providers is critical now as we enter the 2020-21 influenza season and will be even much more so when vaccines for COVID-19 become available in the coming months. Restoring vaccine administration rates is vital to effective and sustainable vaccine delivery and Medicare providers are an integral part of that effort. In that vein, we would urge CMS to use its available authority to make this proposed change in vaccine administration valuation effective prior to January 1, 2021. Timely and appropriate payment for immunization administration that reflects resource cost is critical in maintaining high immunization rates in the United States, as well as having the capacity to respond quickly to vaccinate against preventable disease outbreaks which could create an unnecessary burden on the healthcare systems straining under the COVID-19 epidemic. It is imperative that providers are adequately compensated for efforts being undertaken now to implement vaccination strategies to immunize patients safely so we can avoid further declines in the immunization opportunities for patients most vulnerable to vaccine preventable illness.
Looking ahead, we urge CMS to consider innovative approaches to provide the financial support necessary to address the varied infrastructure needs that future COVID vaccines might require. While vaccine administration costs tend to be fairly consistent, specialized transportation, storage and handling for different COVID-19 vaccines could be complex and costly to providers depending on their location among other factors. AVAC encourages CMS to explore how variable infrastructure costs might be addressed separately from vaccine administration fees as new COVID-19 vaccine become available.
Annual Wellness Visit (AWV) written screening schedule beneficiaries (p. 412)
As the 2021 rule points out, the Annual Wellness Visit (AWV) is a wellness visit that focuses on identification of certain risk factors, personalized health advice, and referral for additional preventive services and lifestyle interventions. In terms of immunization, providers need to have up to date information about routinely assessing the vaccine needs of their patients, strongly recommending needed vaccines, and either vaccinating or referring patients to others who administer vaccinations. Educating adults and their caregivers on their immunization need, particularly those vaccines designed for older adults, have an impact beyond this population – helping to protect children and increasing access to people over the age of 65 or Medicare beneficiaries. The AWV is an important opportunity for providers to educate and encourage patients to receive recommended vaccines and make a patient-centered plan for doing so. AVAC appreciates that the proposed rule includes coding and regulatory additions that will strengthen provider engagement with patients through the AWV and encourages CMS to maintain those additions in the final rule.
MIPS Alternative Measure: Health Information Exchange (HIE) Bi-Directional Exchange (p. 678)
AVAC supports the engagement in bi-directional exchange on immunization data through Health Information Exchange (HIE) and appreciates that the 2021 proposed rule proposes the establishment of a new alternative reporting measure: Health Information Exchange (HIE) Bi-Directional Exchange. The proposed rule points out that there are several benefits to this bidirectional exchange of data. Specifically, the proposed rule notes, “Healthcare quality and public health outcomes have been shown in multiple studies to experience a beneficial effect from health information exchanges with improved medication reconciliation, improved immunization and health record completeness, and improved population level immunization rates. Another study has shown that if every clinician who submits claims under Medicare Part B were connected to an HIE, Medicare would have saved $63 million annually for each therapeutic procedure performed at a physician’s office due to the reduction in duplicate procedures, while other research has shown a decrease in emergency department utilization and improved care process when using an HIE research has shown a decrease in emergency department utilization and improved care process when using an HIE.”
Providers are being called upon to assess and counsel adult patients on recommended immunizations based on their age and health status with the goal of administering needed vaccines or referring patients to other immunization providers. Having access to a patient’s immunization record through bidirectional data exchange is a vital element in clinical decision support and having the ability to report and record data to public health authorities is important for population health as well as surveillance efforts to identify gaps in immunization coverage. Bidirectional exchange of immunization data is vitally important and we hope that the addition of this new measure will help further strengthen and enhance these efforts. AVAC urges CMS to include this new alternative measure in the final rule.
CY2020 MIPS Specialty Measure Sets (Appendix 1, Table B)
Opportunities to assess the immunization status of Medicare beneficiaries should be done by the range of clinicians who care for them, including primary care and specialty providers. Taking advantage of each and every patient encounter to ensure that counseling and education on vaccines, based on their age and health status, and a strong provider recommendation have been found to improve the likelihood of a patient being immunized. AVAC appreciates that MIPS specialty sets include immunization measures in the 2021 proposed rule and urges CMS to maintain those measures in the final rule.
Immunizations are an important public health imperative and ensuring that immunization providers are properly reimbursed is key to fostering a sustained environment of timely immunization. Vaccine administration by health care providers in their office, at the point of care, is an opportunity that needs to be maintained and encouraged. Studies show that inadequate reimbursement for vaccination administration result in missed immunization opportunities and declines in immunization rates.1
We appreciate this opportunity to share our perspective on the proposed rule and are grateful for your work to update and streamline the quality measurement tools available to providers. Please contact an AVAC Coalition Manager at (202) 540-1070 or firstname.lastname@example.org 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 for Professionals in Infection Control and Epidemiology
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
National Association of County and City Health Officials
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