AVAC Offers Comments on the Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022

AVAC managers sent a letter to the Centers for Medicare & Medicaid Services offering comments on the Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022. 

Centers for Medicare & Medicaid Services 
Department of Health and Human Services 
Attention: CMS-1746-P 
P.O. Box 8016 
Baltimore, MD 21244-8016 

To Whom It May Concern: 

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022. 

Specifically, AVAC wishes to highlight its strong support for the following proposals included in this proposed rulemaking: 

  • Efforts to close the Health Equity Gap and the opportunity to offer our views on important actions that are necessary to address longstanding disparities in adult immunization rates among minority and underserved populations. 
  • Adoption of a COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure. 
  • Advancing Health Information Exchange through the development of quality measures and implementation of interoperability standards that will facilitate and improve immunization record reporting and real-time information sharing across health care providers, facilities and public health. 
  • Inclusion of the Adult Immunization Status (AIS) measure in an expanded SNF VBP Program. 

AVAC consists of over 60 organizational leaders in health and public health that are committed to driving federal policy changes that will strengthen and enhance access to adult vaccines and awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions through 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. 

Closing the Health Equity Gap – RFI 

AVAC appreciates the opportunity to respond to the request for information on closing the health equity gap included in the proposed rule. 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. Despite the well-known benefits of immunizations, more than 50,000 adults die from vaccine-preventable diseases while adult coverage has lagged behind Healthy People targets for most commonly recommended vaccines. Disparities in adult vaccination coverage rates are even more acute when broken down by age, race, ethnicity, socioeconomic status and geography. 

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 2020.4 Weekly vaccination rates among Medicare beneficiaries also declined drastically (70%–89% below 2019 rates).5 Long-standing health disparities are also laid bare in these trends. Further, 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. Meanwhile, Black Americans and Hispanic Americans are proportionally receiving less COVID-19 vaccinations than their share of the total population. These trends could have serious consequences for the future, threatening widespread outbreaks of vaccine preventable conditions. We are grateful for CMS’ commitment to addressing systemic inequities that have resulted in poor health outcomes for certain populations. We commend CMS for finalizing in the FY2020 SNF PPS final rule the adoption of standardized patient assessment data elements (SPADEs) that include several social determinants of health (SDOH) and appreciate the opportunity to offer recommendations for expanded measurement and data collection that will help address gaps in health equity with respect to immunizations. 

First, AVAC urges to CMS to promote dissemination and adoption of the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice1. 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. Assessment of immunization status through adoption of NVAC adult standards of care and implementation of adult 

Immunization status measure is a vital component to addressing longstanding disparities in access to immunization and will ensure that all Medicare beneficiaries receive a strong immunization recommendation from their provider and have the resources they need to make an informed decision. 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).

Another important element to closing the equity gap is consistent data collection and real-time reporting. The COVID-19 pandemic has illustrated the need for investments in our nationwide immunization data framework, as well as the dissemination and adoption of federal guidelines and incentives to encourage consistent reporting and widespread utilization of immunization information systems (IIS) across provider settings. In order to effectively identify and address health equity gaps, there must be strong and clear criteria in place for data reporting elements, provider usage, along with baseline standards interoperability, bidirectional exchange, data quality and security. AVAC encourages CMS to work with the HHS Office of Disease Prevention and Health Promotion to include the Healthy People 2030 lifespan IIS reporting3 developmental measure in its strategy to close equity gaps for adult immunization. Robust immunization record data reporting will empower providers, patients and caregivers to make educated decisions about vaccinations, reduce missed opportunities for immunization and minimize the likelihood of overvaccination, and help inform health care system efforts to close health equity gaps and prevent disease outbreaks. 

Lastly, AVAC also expresses support for the use of Quality Improvement Networks and Quality Improvement Organizations (QIN-QIOs) as a means to address the core priority areas outlined in the CMS Equity Plan for Improving Quality in Medicare. The three priority areas which inform CMS policies and programs are: (1) Increasing understanding and awareness of health disparities; (2) developing and disseminating solutions to achieve health equity; and (3) implementing sustainable actions to achieve health equity. The QIN-QIOs have a demonstrated track record of success in testing and evaluating innovative and effective strategies for improving immunization coverage rates among 

targeted Medicare populations. AVAC encourages CMS to continue to utilize the QIN-QIOs for this purpose and urges CMS to include in the list of tasks outlined in future scopes of work (SOW) strategies to improve immunization coverage rates among hard to reach rural and geographically underserved areas as well as among disabled, homebound, inpatient and congregate care patient populations. 

COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure 

AVAC also appreciates the opportunity to express its strong support for CMS’ proposal to add a new COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure to the FY 2023 SNF QRP. The COVID-19 pandemic had a disproportionate and devastating impact on older adults living in long-term care and congregate care settings. This new measure would require SNFs to report on COVID-19 HCP vaccination in order to assess whether SNFs are taking steps to limit the spread of COVID-19 among their HCP, reduce the risk of transmission within their facilities and help sustain the ability of SNFs to continue serving their communities throughout the COVID-19 PHE and beyond. Under this proposal, SNFs would report the vaccination data through the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN) beginning October 1, 2021. 

AVAC believes this measure is vitally important to protect the health and wellbeing of older adults in SNFs and reporting of this measure through the NHSN helps to ensure transparency and accountability in community infection prevention and control efforts and is consistent with other HCP vaccination measures intended to preserve health and mitigate infectious disease outbreaks in long-term care settings. We know from reporting of influenza vaccination coverage of HCPs that provider uptake of the vaccine is also associated with that provider recommending vaccination to patients and encourages greater patient vaccination uptake. HCP vaccination can also potentially reduce illness-related missed work and disruptions to patient care. Lastly, reporting of HCP vaccination rates helps inform patients and caregiver choice when considering facilities from which to seek care, particularly for those at high-risk for developing serious complications from COVID–19. While data on the effectiveness of COVID–19 vaccines to prevent asymptomatic infection or transmission is limited, AVAC believes the COVID-19 HCP vaccination measure should nonetheless be included as part of efforts to assess and reduce the risk of transmission of COVID–19 within SNFs and urges CMS to maintain this proposal in the final rule. 

Fast Healthcare Interoperability Resources (FHIR) in support of Digital Quality Measurement in Quality Reporting Programs – RFI 

AVAC appreciates the work of the Department of Health and Human Services to “encourage and support the adoption of interoperable health information technology and to promote nationwide health information exchange to improve health care and patient access to their health information.” Promoting the use of consistent patient data sets across health care settings can be vitally important to ensure quality patient care and health outcomes while reducing the reporting burden on providers. Additionally, timely and accurate reporting of immunization record data is also of great importance for public health disease surveillance and outbreak prevention activities. Consistent data collection and reporting is a foundational element for successful quality measurement, transparency, and accountability. 

AVAC fully supports greater use of electronic clinical quality measures (ecQMs) across health care programs managed by HHS, including the Centers for Medicare and Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), among other agencies. As CMS seeks feedback on definitions for digital quality measures (dQMs) for the SNF Quality Reporting Program (QRP), we would encourage CMS to look to existing ecQM resources that are available through the National Coordinator for Health Information Technology6 and as well as uniform data system modernization efforts within the Bureau of Primary Health Care at HRSA. Greater consistency in the adoption and use of electronic quality measures and a common reporting standard across HHS programs that serve vulnerable populations of all ages and across health care settings will improve overall quality of patient care, drive better health outcomes, as well as inform and empower patients, without creating an additional complexities and reporting burdens on health care providers. 

In terms of vaccine data for patients in SNF and long-term care settings, AVAC supports incentivizing interoperable and bidirectional immunization data reporting to immunization information systems, leveraging tools and measures through the SNF QRP. As previously stated, provider, patient and caregiver access to immunization record data is essential to addressing health inequities in immunization coverage for the COVID-19, as well as the range of routinely recommended vaccines important to protecting the health and wellbeing of Medicare beneficiaries in long-term care and SNF settings. 

Expanded SNF VBP Program 

AVAC is grateful for the opportunity to present its views in response to the proposed rule request for input from stakeholders on quality measures should be considered under an expanded SNF VBP. As the proposed rule notes, the Consolidated Appropriations Act, 2021 allowed the Secretary to expand the SNF VBP program and apply up to ten measures with respect to payments beginning in FY 2024, which may include measures of functional status, patient safety, care coordination, or patient experience. 

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 COVID-19 pandemic and annual flu seasons. As CMS notes, the expanded SNF VBP measure set assess the quality of care that long-term care facilities provide, regardless of payer, but certainly the vast majority of patients are beneficiaries. 

Adult Immunization Status Measure 

As CMS considers a range of measures aimed at the quality of patient care with the goal of improving the overall patient experience and health outcomes, AVAC urges CMS to include of an Adult Immunization Status (AIS) measure in an expanded SNF VBP. 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 assesses the receipt of routinely recommended adult immunizations vital to healthy aging and prevention of avoidable illness. The AIS would reduce the reporting burden on providers while also incentivizing them to follow 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. 

Several years ago, AVAC released a White Paper outlining the value and imperative of quality measures for adult vaccines.2 The report highlights the role of vaccine quality measures in preventing illness and death, reducing caregiving demands, avoiding unnecessary healthcare spending, and setting the foundation for healthy aging. Quality measurement programs through 

Medicare play a critical role in promoting improved quality and encouraging adherence to and consistent utilization of recommended adult vaccines. 

The addition of an AIS quality measure to the SNF VBP would meet 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. 

Thank you again for the opportunity to share our perspective on this proposed rule. Please contact an AVAC Coalition Manager at (202) 540-1070 or lfoster@adultvaccinesnow.org if you wish to further discuss our comments. To learn more about the work of AVAC visit www.adultvaccinesnow.org. 


Lisa Foster, AVAC Manager
Abby Bownas, AVAC Manager