March 1, 2016

RE: CMS Quality Measurement Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) Quality Measure Development Plan (MDP).

AVAC consists of 46 organizational leaders in health and public health that are committed to tackling 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 mission is informed by a growing body of scientific and empirical evidence in support of the benefits immunizations provide by 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.

AVAC 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 more comprehensive tracking and reporting of immunization status that will result in increased adult immunization rates.

Measure Development Plan Purpose

AVAC supports the range of CMS work currently being undertaken to streamline process and outcome measures and align these measures across providers and payment systems. This extensive undertaking requires a coordinated effort that includes public and private payers, health care providers as well as patients and caregivers. AVAC appreciates that CMS is committed to the goals of addressing known measurement and performance gaps while also employing strategies to ensure that the burden of quality measure reporting on providers is minimized.

Immunizations are a cornerstone of our nation’s disease prevention efforts and have a demonstrated track record of success as a cost-effective means of reducing disease burden and saving lives among pediatric populations. Yet, despite the well-known benefits of immunizations, more than 50,000 adults die from vaccine-preventable diseases while adult coverage remains well below Healthy People 2020 targets for most commonly recommended vaccines (influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, HPV). Millions more adults suffer from vaccine-preventable diseases, causing them to miss work and leaving them unable to care for those who depend on them. Immunization meets the three aims of the CMS Quality Strategy — Better Care; Smarter Spending; and Healthier People. We urge CMS to consider the development of additional adult immunization quality measures that align with the age and health status recommendations of the Advisory Committee for Immunization Practices (ACIP). Prioritizing additional quality measures around immunizations through MACRA funding as part of the MDP would help to address identified measure gaps, improve upon immunization rates and create greater health outcomes across adult populations.

CMS Strategic Vision

AVAC supports consistent and comprehensive quality measure sets for widespread use to inform clinical decision making at the point of care and improve quality in the provider setting. CMS has made the alignment of quality measures with the National Quality Strategy (NQS), the CMS Strategic Plan, and other CMS quality reporting and value-based purchasing programs a priority. AVAC fully supports the alignment of reporting mechanisms and believes doing so will strengthen and enhance the development and implementation of adult immunization quality measures. Over the past year, AVAC has submitted numerous regulatory comment letters urging greater standardization of immunization measures across CMS programs, including the physician quality reporting system (PQRS), the meaningful use and electronic health records (MU/EHR) inventive programs and new merit incentive payment systems (MIPS). AVAC is also in agreement with the general and technical principles set forth in the draft MDP.

The draft MDP references a number of important baseline quality measures, as well as relevant publications and reports aimed at informing the quality measure framework and development process. AVAC would urge you to consider the August 2014 NQF report “Priority Setting for Healthcare Performance Measurement: Addressing Performance Measure Gaps for Adult Immunizations”, which provides a comprehensive overview of the current state of adult immunization measures and gap analysis on areas where more work is needed. In general, the report highlights the lack of measures for certain vaccine-preventable conditions that disproportionately affect adults (e.g. herpes zoster), while other diseases that significantly impact adults, particularly the elderly and those with chronic conditions (e.g. influenza and pneumonia) have multiple, overlapping measures across CMS programs. We agree with NQF’s finding that reducing the burden and improving the value of measurement and measures should be harmonized and consolidated and “at a minimum, all measures should be up to date with current ACIP/CDC recommendations.”1 We also support their proposed short-term and long-term prioritization of measurement needs. This includes a process for quality measures for newly approved ACIP recommended vaccines.

Operational Requirements of the Quality Measure Development Plan

The MDP outlines the nine MACRA requirements of the MDP and sets for CMS’ proposed approach to each requirement. AVAC would like to offer the comments with regard to each of the following MACRA requirements.

1) Multi-Payer Applicability of Measures – CMS outlines the variety of initiatives designed to create aligned core measure sets across both public and private payers. These efforts include the Measure Applications Partnership (MAP), the Core Quality Measures Collaborative and the Health Care Payment Learning and Action Network (HCPLAN).

a. Measure Applications Partnership – AVAC was pleased to submit comments to the NQF MAP in December 2015 in response to the 2015 measures under consideration. Those comments supported process measures for immunization against hepatitis A and hepatitis B as well as influenza for Medicare beneficiaries with liver diseases and urged NQF to continue building and improving upon immunization measures currently found in PQRS as work to develop core measures for MIPS continues.

b. Core Quality Measures Collaborative – AVAC appreciates the work of the Collaborative in producing 7 core measure sets that will be expanded upon and finalized through a formal rulemaking process. We were disappointed immunizations were not included in the initial round of measure sets given they represent one of the most cost effective means of primary prevention, especially in adults with chronic conditions. We look forward to working with the Collaborative to ensure that immunization is an integral part of measure sets moving forward.

c. Health Care Payment Learning and Action Network (HCPLAN)— AVAC is pleased to be a member of HCPLAN and appreciates the working group designed to tackle specific issues and challenges around the development of new payment models.

2) Coordination and Sharing Across Measure Developers – AVAC strongly supports CMS efforts to coordinate and share knowledge and best practices among federal and non-federal quality measure development partners. This approach will ensure strong measures that can be adopted across payment settings and providers. Greater attention and focus on adult immunization measures will strengthen prevention efforts while reducing the burden on providers and providing a more meaningful and effective core set of measures in this area. Consistent application of immunization measures by providers and health care settings will enable seamless tracking of a patient’s immunization status and provide an accurate and complete record that will help inform and improve clinical decision-making and health outcomes, reduce missed opportunities to immunize as well as protect against over immunizing.

3) Clinical Practice Guidelines – MACRA requirements call for CMS to take into account clinical best practices and guidelines in the development of quality measures. AVAC urges CMS to consider the recommendations of the Advisory Committee on Immunization Practices (ACIP) as a resource on adult immunization. ACIP is a formal advisory group of medical and public health experts who develop evidence-based recommendations on the appropriate use of vaccines, including at what ages a vaccine should be given, number of doses needed and intervals, as well as potential contraindications. These recommendations represent the gold standard in immunization clinical practice.

4) Evidence Base for Non-Endorsed Measures – The MDP indicates that CMS plans to “use the rating criteria established by NQF to evaluate the quality, quantity and consistency of the evidence for the development of quality measures included in the plan.”2 AVAC urges CMS to conduct an extensive gap analysis to identify ACIP-recommended adult immunizations for which there is no corresponding quality measure and work with measure developers to address these gaps.

5) Quality Measure Domains and Priorities – The MDP outlines a series of quality domains required under MACRA. AVAC urges CMS to give serious consideration to adult immunization quality measures under the population health and prevention quality domain. The IOM report “Vital Signs: Core Metrics for Health and Health Care Progress” highlights the value of preventive services such as immunization, noting that, “more than 75 percent of U.S. health care expenditures is related to the treatment of preventable conditions, only an estimated 3 percent is devoted to prevention and public health improvement activities.”3 Immunization is “effective prevention” to reduce rates of morbidity and mortality from a growing number of preventable conditions and has been demonstrated to improve overall health.

6) Gap Analysis – The MDP indicates that CMS will prioritize the development of measures in areas where gaps in provider performance and variation in care present opportunities for meaningful improvement. We strongly urge CMS to review the findings and adopt the recommendations of the August 2014 NQF report “Priority Setting for Healthcare Performance Measurement: Addressing Performance Measure Gaps for Adult Immunizations”.

7) Applicability of Measures Across Healthcare Settings – AVAC supports CMS efforts to streamline and standardize quality measures for use across health care settings and providers. We urge CMS to prioritize adult immunization measures through the MDP and related quality measure processes by conducting a comprehensive review of existing adult measures, streamlining redundant and outdated measures currently being used, while also working to address identified gaps in adult immunization measures by rapidly advancing new measures covering a broader array of ACIP recommended vaccines for adults. We believe such an effort would provide a solid foundation of strong core immunization measures as we transition to new payment models that will rely heavily on accurate and effective quality performance measures.

8) Clinical Practice Improvement Activities – The National Immunization Survey tracks progress in immunization rates across a range of preventable conditions, looking at specific age groups and populations. Our nation is woefully deficient in advancing adult immunization coverage, particularly among the elderly and underserved communities of color. AVAC encourages CMS to include adult immunization measures among the clinical practice improvement activities.

9) Consideration for Electronic Specifications – AVAC supports CMS efforts to leverage and integrate broader access to a range of data originating from patient registries, clinical data repositories and common data elements. AVAC was also pleased to offer comments in response to the proposed electronic clinical quality measures (eCQMs) for influenza immunization for use by providers in CMS quality reporting programs and hopes CMS will work to put forth additional eCQMs pertaining to adult immunization.

Thank you for the opportunity to offer our perspective on the MDP. Adult immunization measures have been integral to existing CMS quality measures systems and should be a core element in future quality measurement frameworks. Please contact an AVAC manager at (202) 540-1070 or info@adultvaccinesnow.org if you wish to discuss our comments or adult immunization.

American College of Preventive Medicine
Asian & Pacific Islander American Health Forum (APIAHF)
Biotechnology Innovation Organization (BIO)
Immunization Action Coalition
National Viral Hepatitis Roundtable (NVHR)
Novavax
Pfizer
Sanofi Pasteur
Takeda
The Gerontological Society of America