AVAC Submits Comments on the Hospital Outpatient Prospective Payment

On September 17, AVAC submitted comments on Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; etc.

To Whom It May Concern: 

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; etc. 

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

  • Adoption of a COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure for the Hospital OQR and ASCQR Program Measure Sets Beginning with the CY 2022 Reporting Period/CY 2024 Payment Determination 
  • Greater use of electronic clinical quality measures (ecQMs) across health care programs managed by HHS. 
  • Potential Future Efforts to Address Health Equity in the Hospital OQR and the ASCQR Programs to include bolstering immunization through the following actions:
    • Facilitating dissemination and adoption of the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice; 
    • Encouraging CMS to work with the HHS Office of Disease Prevention and Health Promotion to incorporate the increase in the proportion of adults age 19 or older who get recommended vaccines developmental measure2 in its strategy to close equity gaps for adult immunization and; 
    • Supporting CMS’ proposed 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 to address inequities and gaps in access to adult immunization. 

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. 

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

AVAC appreciates the opportunity to express strong support for CMS’ proposal to add a new COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure to the FY 2023 Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgical Center Quality Reporting (ASCQR) Programs. The COVID-19 pandemic had a disproportionate and devastating impact on communities of color and older adults. This new measure would require hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) to report on COVID-19 HCP vaccination rates to assess to what extent these facilities are taking steps to limit the spread of COVID-19 among their HCP, reduce the risk of transmission within their facilities so they can continue to serve their communities throughout the COVID-19 Public Health Emergency (PHE) and beyond. Under this proposal, HOPDs and ASCs would report the vaccination data through the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN) beginning October 1, 2021 through December 31, 2021. 

AVAC believes this measure is vitally important to protect the health and wellbeing of our community, particularly older adults and individuals with chronic conditions. Reporting of the COVID-19 for HCP measure through the NHSN will help 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 the healthcare setting. 

We know from reporting of influenza vaccination coverage of HCPs that uptake of the vaccine is also associated with those providers recommending vaccination to their patients, which in turn 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. AVAC believes the COVID-19 HCP vaccination measure should be included efforts to assess and reduce the risk of transmission of COVID–19 within healthcare settings and urges CMS to maintain this proposal in the final rule. 

The proposed rule includes a shortened reporting period of October through December 2021. AVAC supports the proposed timeframe and appreciates that the COVID-19 HCP reporting period and measure specifications align closely with the Influenza HCP vaccination measure (NQF 0431). 

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 utmost 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 HOPDs, we would encourage CMS to look to existing ecQM resources that are available through the National Coordinator for Health Information Technology 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 complexity and reporting burdens on health care providers. 

In terms of vaccine data for patients in HOPDs and ASCs, AVAC supports incentivizing interoperable and bidirectional immunization data reporting to immunization information systems, leveraging tools and measures through the hospital OQR and ASCQR programs. 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 the hospital outpatient and ASC care settings. 

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. 

Request for Comment on Potential Future Efforts to Address Health Equity in the Hospital OQR and the ASCQR Programs 

AVAC appreciates the opportunity to respond to the request for comment on addressing health equity in the Hospital OQR and ASCQR programs discussed 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. Prior to the pandemic more than 50,000 adults died from vaccine-preventable diseases each year in the United States. While adult coverage has lagged Healthy People targets for most routinely 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.” 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 Centers for Disease Control and Prevention (CDC) recommended vaccines declined between 41%-53% from March-August 2019 as compared to March-August 2020.7 Weekly vaccination rates among Medicare beneficiaries also declined drastically (70%–89% below 2019 rates) 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.8 Meanwhile, Black Americans and Hispanic Americans are proportionally receiving less COVID-19 vaccinations than their share of the total population. These trends have had serious consequences on our nation’s ability to achieve herd immunity, resulting in continued outbreaks across the country. We are grateful for CMS’ commitment to addressing systemic inequities that have resulted in poor health outcomes for certain populations and look forward to working with the agency on this important goal. 

As CMS looks for ways to address health equity in the context of the Hospital OQR and ASCQR programs, AVAC would urge CMS to consider the following actions with regard to immunization: 

  • 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. Consistent assessment of immunization status through adoption of NVAC adult standards of care and implementation of adult immunization status measure are vital components 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 the Hospital OQR and ASCQR programs to close equity gaps for adult immunization in these outpatient care settings. Robust immunization record data reporting will empower providers, patients and caregivers to make educated decisions about vaccinations, reduce missed opportunities for immunization, 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. 

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. 


American Immunization Registry Association (AIRA) 
Alliance for Aging Research 
Biotechnology Innovation Organization 
Dynavax Technologies Corporation 
Families Fighting Flu 
Immunization Action Coalition 
Infectious Disease Society of America 
Merck & Co Inc. 
National Association of Nutrition and Aging Services Programs 
National Consumers League 
STChealth LLC 
The Gerontological Society of America i 
Trust for America’s Health