FROM: The Adult Vaccine Access Coalition (AVAC)
TO: Centers for Medicare & Medicaid Services
DATE: September 6, 2022
RE: CMS-1770-P Medicare Program: CY 2023 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements etc.
The Adult Vaccine Access Coalition (AVAC) appreciates the opportunity to comment on Medicare Program: CY 2023 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements etc.
- Appreciates the Centers for Medicare and Medicaid Services (CMS) continues to recognize stakeholder concerns about the multi-year reduction in Medicare payment rates for vaccine administration.
- Supports maintaining the $40 payment for COVID-19 vaccine administration and the $30 payment for vaccine administration for all other routinely recommended vaccines.
- Urges CMS to bolster efforts to close the Health Equity Gap and overcome underutilization of high value immunization services by facilitating dissemination and adoption of the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice1
- Encourages CMS to maintain the Adult Immunization status measure for the MIPS quality payment program in the final rule.
AVAC’s broad membership consists of over seventy 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.3
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.4 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.5 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 CY23 proposed rule continues to acknowledge stakeholder concerns about the multi-year reduction in Medicare payment rates for vaccine administration and proposes to maintain the vaccine administration payment of $40 for COVID-19 vaccines and $30 for other routinely recommended 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.
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 that more than 37 million doses of routinely recommended vaccines have been missed during the pandemic.6 Equitable and sustained payment rates for vaccine services are vital to delivery and supporting the range of Medicare providers who are an integral to COVID-19 vaccination efforts as well as recovery of missed routine vaccines.
Vaccine Administration Services – Payment for COVID-19 Vaccine Administration in the Home
AVAC appreciates CMS proposal to maintain the at-home add-on payment for COVID–19 vaccine administration for another year and encourages CMS to consider expanding this add-on payment to all routinely recommended Part B vaccines in the future. The add-on payment rate of for COVID–19 vaccines that are administered by a provider in the beneficiary’s home continues to be important strategy to address immunization inequities for 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.
We agree with CMS that we believe continuing the additional payment for at-home COVID-19 vaccinations for another year would provide time to better understand utilization and trends associated with its use that could inform vaccine administration policy for CY 2024. While we are disappointed that CMS will not be extending the policy to include the other preventive vaccines, AVAC hopes the agency will reconsider in the future. 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.
Request for Information: Medicare Potentially Underutilized Services
AVAC appreciates the opportunity to respond to the request for information on potentially underutilized services under Medicare, including immunizations/vaccinations. We are also grateful for CMS’ recognition of the longstanding disparities in access to healthcare for certain populations and for the commitment to solutions to address these equity gaps.
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.”10 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:1
- 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). 10
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 timely and accurate data frameworks, 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.
Adult Immunization Status Measure (Appendix 1 A.9)
AVAC strongly supports the inclusion of Adult Immunization Status (AIS) as a MIPS quality measure encourages CMS to maintain the measure in the final rule. The AIS measure is a composite of several age-recommended vaccines for adults, comprising influenza, pneumococcal, zoster, and Tdap vaccines. Adoption of the composite measure will provide a sound, reliable and comprehensive means to assess the receipt of routinely recommended adult immunizations. The AIS will reduce the reporting burden on providers while also incentivizing adoption of the National Vaccine Advisory Committee (NVAC) Practice Standards for Adult Immunization Practice1 to assess, recommend, administer or refer and document the vaccines the patient may (or may not) have received during the office visit. It will also improve electronic health record data quality and reporting. Quality measurement through Medicare is critical to promoting improved quality and encouraging adherence to and consistent utilization of recommended adult vaccines.
The AIS is a valuable addition because it meets the three core strategies underlying the movement toward a truly patient-centered health care delivery system by: 1) Improving the way clinicians are paid to incentivize quality and value of care over simply quantity of services; 2) improving the way care is delivered by providing clinical practice support, data and feedback reports to guide improvement and better decision-making and; 3) making data more available in real-time at the point of contact and enabling the use of certified Electronic Health Record (EHR) technology and other data sources to support care delivery.
Immunizations remain 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 well beyond the COVID-19 public health emergency.
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.