June 17, 2016

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1655-P
P.O. Box 8016
Baltimore, MD 21244-8016

RE: CMS–1655–P Medicare Program proposed rule on 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 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; and Technical Changes Relating to Costs to Organizations and Medicare Cost Reports.

To Whom It May Concern:

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Medicare Program Hospital Inpatient Prospective Payment proposed rule.

AVAC consists of organizational leaders in health and public health that are committed to tackling the range of barriers to adult immunization and to raising awareness of and engaging in advocacy on the importance of adult immunization. Our mission is informed by a growing body of scientific and empirical evidence of the benefits of immunization through 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.

A top priority for AVAC is to achieve increased adult immunization rates through federal benchmarks and measures that encourage tracking and reporting of recommended vaccines. Immunization quality measures are a crucial tool for health care quality improvement and have demonstrated effectiveness in increasing immunization rates.

Preventing transmission of influenza and other infectious agents within inpatient healthcare settings requires a multi-faceted approach since the spread of influenza can occur among patients, Health Care Professionals (HCP), and visitors. Required measures through the Medicare hospital inpatient program play a critical role in promoting improved care quality facilitating adherence to the influenza vaccine.

VBP Program. In FY 2018, CMS removed NQF#1659 IMM-2, the Influenza Immunization Measure, from the Hospital VBP Program. AVAC urges CMS to once again include this important measure as part of the Hospital VBP program. The Advisory Committee on Immunization Practices (ACIP) recommends an annual influenza vaccination for all people age 6 months or older. Each year, influenza causes approximately 200,000 hospitalizations and 36,000 deaths in the United States. It also costs the United States about $16 billion annually to treat this vaccine-preventable disease among US adults 50 or over. Having IMM-2 as part of the VBP Program will help increase access and utilization of this important vaccine by ensuring that healthcare providers offer recommended vaccines to their patients.

IQR. We support the proposal to maintain IMM-2 (NQF #1659) as part of the Hospital Inpatient Quality Reporting (IQR) program for FY 2019 and subsequent years. This measure plays a critical role in the CMS Quality Strategy as well as the National Quality Strategy in terms of influenza immunization efforts.

Data Stratification. AVAC coalition members are working on projects that seek to identify and enhance our understanding of coverage gaps and are developing pilot programs to test targeted solutions where these disparities currently exist. We support the idea of future stratification of Hospital IQR Program data by race, ethnicity, sex, and disability on Hospital Compare, as well as on potential future hospital quality measures that incorporate health equity. Additionally, we recommend that the data also be stratified by primary language. Together, this type of data will enable more accurate evaluation in coverage gaps and disparities, particularly among minority and vulnerable populations, and are essential to improving the impact of adult immunization efforts and expanding coverage.

New Measures. We value your request for comment on potential new quality measures under consideration for future inclusion in the Hospital IQR Program. While we do not wish to specifically comment on the three new measures proposed, we would like to call attention to the importance of all ACIP recommended vaccinations. The 2014 National Healthcare Quality and Disparities Report by the Agency for Health Care Research and Quality (AHRQ) found that publicly-reported CMS measures were much more feasible than measures reported by other sources to stimulate high levels of performance. Additionally, CMS’ Quality Improvement Network Quality Improvement Organization (QIN-QIO) 11th Scope of Work (SOW) includes strategies aimed at improving reporting of all adult immunizations and increasing immunization rates among the Medicare population.

In this vein, we would like for CMS to revisit the elimination of the IMM-1 (Pneumococcal Immunization -NQF #1653) from the Hospital IQR Program in FY2016 for the FY 2018 payment determination and in subsequent years. Pneumonia is responsible for over a million hospitalizations and 50,000 deaths each year in the United States. Vaccines are an effective intervention against the high cost of medical care and rates of preventable death associated with this disease, particularly among medically vulnerable populations and the elderly. That is why the 2014 Advisory Committee for Immunization Practices (ACIP) recommendations call for adults aged 65 years or older and individuals with underlying immunocompromising health conditions between 19 and 64 years of age to receive PCV13 and PPSV23. ACIP also recommends PPSV23 for adults 19 through 64 years of age with underlying chronic health conditions like diabetes, heart disease, liver disease or lung disease (including people who smoke or have asthma). We strongly encourage CMS to prioritize adding the pneumococcal immunization measurement back into the Hospital IQR program.

Public Display of Measures.

Preventing transmission of influenza virus within healthcare settings requires a multi-faceted approach. We see surveillance as a key component in prevention and management of influenza outbreaks. We agree that LTCH QRP data should be publicly available on a CMS website, such as Hospital Compare. Specifically, we support your proposal to publicly report in CY 2017, pending the availability of data, on facility-wide influenza vaccination coverage among Healthcare Personnel (NQF #0431). Recent studies have suggested that vaccination of nursing home staff members may reduce the incidence of influenza among nursing home residents. Current national estimates of employee vaccination rates (around 50%) indicate that residents may be at an unnecessarily high risk of contracting influenza1,2. Tracking vaccine status among health care workers has the ability to increase vaccination rates and reduce absenteeism among healthcare personnel.

Additionally, we support the public reporting of data around the “Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680).” As influenza vaccines can be accessed through multiple settings, we support the suggested proposal that criteria be based on patients who 1) receive the influenza vaccine during the influenza season; 2) are offered and declined the influenza vaccine; and 3) who are ineligible for the influenza vaccine due to contraindication(s).

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,

American College of Preventive Medicine
Asian Pacific Islander American Health Forum
BIO
Dynavax
Gerontological Society of America
GSK
Immunization Action Coalition
National Association of County and City Health Officials
Pfizer
Sanofi
Takeda
Trust for Americas Health