As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) 2017 Medicare Advantage and Part D Advance Notice and Draft Call Letter.

AVAC consists of over 45 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 efforts to address specific challenges vulnerable populations face in order to close gaps in immunization coverage and improve adult immunization rates overall.

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. At risk populations, including the frail elderly, also lag behind Healthy People 2020 adult immunization goals, yet are particularly vulnerable to the adverse health consequences of vaccine preventable illness.

Immunization coverage for Medicare beneficiaries is segmented between Medicare Part B, which covers vaccinations against influenza, pneumococcal and hepatitis B for at-risk patients and Medicare Part D, which covers all other commercially available vaccines. While beneficiaries receive Part B-covered vaccines with no cost sharing, Part D vaccines are typically subject to cost sharing requirements. Significant beneficiary cost sharing under Medicare Part D create barriers to access and may hinder public health and provider efforts to improve rates among these subgroups.

Immunization meets the three aims of the CMS Quality Strategy — Better Care; Smarter Spending; and Healthier People and should be strengthened and enhanced in order to provide greater access to and utilization of adult immunization services amongst the Medicare population. In this vein, AVAC would like to offer comments with regard to the following sections of the 2017 draft call letter that we believe would strengthen adult immunization amongst Medicare beneficiaries.

Changes to Star Ratings Measures for MA Plans (page 146)

The draft call letter indicates that the National Committee for Quality Assurance (NCQA) is presently considering a modification to the “Pneumococcal Vaccination Status for Older Adults” measure collected by the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. This patient-based survey measure assesses the percentage of Medicare members 65 years of age and older who have ever received a pneumococcal vaccination. AVAC was pleased to submit comments in support of the interim change to better account for the 2014 Advisory Committee on Immunization Practices (ACIP) recommendation that all adults 65 years of age and older receive sequential administration of both PCV13 and PPSV23. While the proposed question does not specify PCV13 and PPSV23, the order in which patients should be vaccinated, or the amount of time between which the two immunizations should initially occur, we believe this interim step will improve alignment with current guidelines and help provide better information in terms of whether or not adults age 65 and older are being accordance with ACIP recommendations for pneumococcal vaccination.

Last year, the Health and Well-Being Committee for the National Quality Forum (NQF) proposed standards specifications for pneumococcal measures in order to better align measures across healthcare settings and to bring measures in accordance with ACIP recommendations.1 AVAC encourages CMS to continue to work with NCQA and other relevant quality measure stakeholders to update, refine and streamline pneumococcal vaccination-related quality measures.

Maintains $0 cost sharing tier recommendation (page 189)

The 2017 draft call letter notes the continued lack of meaningful progress toward Healthy People 2020 targets. Despite ACIP’s evidence-based clinical guidelines on the appropriate ages and dosing of recommended vaccines for adult immunization, rates still remain extremely low. According to 2014, CDC National Health Information Survey (NHIS) data, disparities in adult immunization coverage rates are even more striking among communities of color, limited English proficient persons, and people with chronic illness.

There is a growing body of scientific evidence that indicates financial barriers to Part D vaccines impede beneficiary access to immunization services. For instance, a 2011 Government Accountability Office (GAO) report on factors affecting access to Medicare Part D vaccinations found that many of the almost 22 million Medicare beneficiaries age 65 and older who were enrolled in Medicare Part D in 2009 did not receive the routinely recommended vaccinations covered by Part D.3 The GAO report survey of physicians found that physicians often cited cost sharing affordability for beneficiaries as a barrier to access to recommended vaccines. Last year, an Alliance for Aging Research report on vaccination rates among older adults found that cost sharing for vaccines under Part D varies depending on a beneficiary’s prescription drug plan or Medicare Advantage plan formulary offerings.4 Recently, a report by Avalere Health found between 47 and 72 percent of the 24 million Medicare beneficiaries with Part D coverage had some level of cost sharing for vaccines, ranging from $35 to $70 in 2015. 5AVAC strongly supports CMS call letter language encouraging Part D sponsors to consider offering $0 or low cost sharing for vaccines.

We encourage CMS to maintain this language in the final letter and further emphasize the importance of this benefit and work more aggressively to address the barrier of cost sharing to beneficiary access to this essential preventive health service. Specifically, AVAC urges CMS to consider offering incentives, such as allowing to Part D plan sponsors count spending on beneficiary education campaigns and other efforts to promote access to ACIP recommended vaccines toward medical loss ratio (MLR) totals, when those plans transition vaccines from higher cost sharing tiers to the $0 cost sharing tier option.

The variable cost sharing requirements currently imposed on the majority of Part D vaccines discourages immunization among elderly, disabled and chronically ill populations who account for disproportionate percentage of the morbidity and mortality from vaccine preventable conditions. Removing this financial barrier would have a significant impact on beneficiary access and utilization of Part D vaccines. As new vaccines for a growing variety of infectious and devastating conditions enter the market, reducing this barrier will be even more important to improving uptake that will save lives and money.

Improvement Measures for MA and Part D plans (page 226)

The draft call letter indicates that the annual influenza vaccine is being considered for inclusion among process improvement measures for which Medicare Advantage (MA) plans will be judged.

The 2015 Institute of Medicine (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.”6

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.

According to the Centers for Disease Control and Prevention (CDC), influenza alone cost $10.4 billion in direct health care costs during the 2013-14 flu season.7 However, CDC estimates that each influenza vaccination saves $80 per year per person vaccinated, averting 90,000 hospitalizations. AVAC supports the inclusion of annual influenza immunization among MA process improvement measures as a means to ensure this critical disease prevention tool is being utilized.

Thank you for the opportunity to offer our perspective on the 2017 Medicare Advantage and Part D Advance Notice and Draft Call Letter. We hope CMS will reinforce its call for Part D plans to include vaccines in the $0 cost sharing tier in the final letter and work to find the right balance between plans’ fiduciary responsibilities and beneficiary access to essential preventive health services. Please contact an AVAC manager at (202) 540-1070 or info@adultvaccinenow.org if you wish to discuss our comments or adult immunization.

Sincerely,

Alliance for Aging Research
American College of Preventive Medicine (ACPM)
Asian & Pacific Islander American Health Forum (APIAHF)
Biotechnology Innovation Organization (BIO)
Immunization Action Coalition
National Association of City and County Health Officials (NACCHO)
Sanofi Pasteur
Takeda Vaccines
The Gerontological Society of America