AVAC Comments on the CY 2021 Home Health Proposed Rule

AVAC submitted comments to CMS on the CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; Home Infusion Therapy Services Requirements proposed rule. AVAC appreciated that the proposed rule maintains Influenza Immunization Received for the Current Flu Season among the 20 measures currently adopted for the 2022 Home Health Quality Reporting Program (HHQRP).

August 24, 2020

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-1730-PP.O. Box 8013,

Baltimore, MD 21244-8013

RE: CMS-1730-P Medicare and Medicaid Programs; CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; Home Infusion Therapy Services Requirements

To Whom It May Concern:

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; Home Infusion Therapy Services Requirements proposed rule.

AVAC consists of over 55 organizational leaders in health and public health that are committed to addressing the range of barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our priorities and objectives are driven by a consensus process with the goal of enabling the range of stakeholders to have a voice in the effort to improve access and utilization of adult immunizations. One of our key coalition priorities is to advocate for federal benchmarks and quality measures to encourage improved tracking and reporting of immunization status that will result in increased adult immunization rates.

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 current COVID-19 pandemic and upcoming flu season this fall. Unfortunately, access to vaccines is not equal across a person’s lifespan.

Despite the well-known benefits of immunizations, adults routinely die from vaccine-preventable diseases and adult coverage has lagged behind federal targets for most commonly recommended vaccines for a number of years: influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, and HPV. Now more than ever before, Home Health Agencies (HHAs) are essential community providers for older adults and disabled patients and have an increasingly important role to play in improving vaccine access and utilization. Home health visits provide a unique opportunity to assess the patient in their home environment and employ a multidisciplinary approach to patient care. Incorporating vaccine assessment and administration during a home health episode optimizes patient care by removing a significant barrier to access, transportation for homebound patients. Studies have shown that multidisciplinary healthcare providers can have a significant impact on vaccine administration rates in a home setting1. The National Vaccine Advisory Committee’s (NVAC) Adult Immunization Standards call for all providers caring for adult patients to assess, recommend, vaccinate or refer, and document vaccinations.2

Our coalition firmly believes that adult immunization quality measurement is central to ensuring continued focus on this high value prevention intervention. Even circumstances where HHA patients are offered a recommended vaccine but decline or patients who are ineligible to receive a vaccine due to contraindications present important learning opportunities.

Quality Measures Currently Adopted for the CY 2022 HH QRP

 We appreciate that the proposed rule maintains Influenza Immunization Received for the Current Flu Season among the 20 measures currently adopted for the 2022 Home Health Quality Reporting Program (HHQRP). This measure will be especially important for the upcoming flu season as well as next year’s flu season to emphasize that beneficiary immunization status with respect to influenza remains a core prevention priority for CMS.

In ordinary times, influenza represents a serious risk to the health and overall wellbeing of older adults, particularly among those beneficiaries with disabilities and chronic conditions. A CDC study of flu- associated deaths prevented over a nine-year period from 2005-2006 through 2013-2014 found that nearly 89 percent were in people 65 years of age and older. Each year, influenza causes approximately 200,000 hospitalizations and an average of 36,000 deaths in the United States alone. Achieving the highest possible influenza vaccination rate for the 2020-21 and 2021-22 flu seasons is going to be extremely important as scarce health care resources need to be preserved for the fight against COVID-19.

Influenza immunization measures help increase access and utilization of this important vaccine by patients and health care providers alike and AVAC urges CMS to maintain the influenza measure in the final rule.

Immunizations beyond influenza also provide especially high value among patients with chronic conditions, such as diabetes or chronic heart disease, who are at higher risk of adverse health consequences resulting from vaccine-preventable diseases.3 The Centers for Disease Control and Prevention (CDC) estimates 900,000 Americans get pneumococcal pneumonia each year, resulting in as many as 400,000 hospitalizations and more than 53,000 deaths. Among adults age 65 and older, the annual cost of pneumococcal disease is over $3 billion dollars. Despite the fact that most pneumococcal pneumonia deaths each year are adults, pneumococcal vaccination rates remain inadequate, with only 63 percent of adults over the age of 64 and 22 percent of high-risk adults being vaccinated.

In the future, AVAC believes the HH QRP should include a focused, concerted effort to improve access and utilization of all Advisory Committee on Immunization Practices (ACIP) recommended adult immunizations as a means of improving the overall health of Medicare beneficiaries receiving home health services.

We look forward to working with CMS to ensure meaningful measures that reflect priority health care services, such as immunization, that also provide an accurate representation of HHA performance in the least burdensome manner possible can be included in the home health value-based and quality reporting programs in future comment cycles. The National Committee on Quality Assurance (NCQA) has spearheaded the testing of a new composite measure for adult immunization, along with measures for maternal immunization and end-stage renal disease patients. The adult immunization composite measure incorporates multiple ACIP-recommended vaccines and we look forward to working with CMS to support the widespread adoption of the measure. An adult composite measure would provide a sound, reliable and comprehensive means to assesses the receipt of routine adult vaccinations recommended by the ACIP. AVAC strongly supports reliable measurement tools that will streamline the patchwork of existing adult immunization measures, reduce the reporting burden on providers, and provide meaningful data to the Medicare program on access to this important preventive service.

We appreciate this opportunity to share our perspective on this proposed rule. Please contact an AVAC Coalition Manager at (202) 540-1070 or info@adultvaccinesnow.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

Asian & Pacific Islander American Health Forum

Biotechnology Innovation Organization (BIO)

Every Child by Two

Families Fighting Flu

Gerontological Society of America


Immunization Action Coalition


National Association of Nutrition and Aging Services Programs (NANASP)

National Foundation for Infectious Diseases (NFID)

National Hispanic Medical Association (NHMA)

National Viral Hepatitis Roundtable







  1. https://www.jscimedcentral.com/FamilyMedicine/familymedicine-3-1074.pdf
  2. http://www.publichealthreports.org/issueopen.cfm?articleID=3145
  3. http://www.cdc.gov/Mmwr/preview/mmwrhtml/mm6404a6.htm