August 26, 2016
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1648-P
P.O. Box 80136
Baltimore, MD 21244-8016

RE: Medicare and Medicaid Programs: CY 2017 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements

To Whom It May Concern:

AVAC appreciates the opportunity to offer comments in response to the Medicare and Medicaid Programs: CY 2017 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing (HHVBP) Model; and Home Health Quality Reporting Requirements. As a stakeholder coalition interested in advancing new payment models that encourage access to immunization, we are grateful to Centers for Medicare and Medicaid Services (CMS) for its work in this area.

AVAC consists of over 50 organizational leaders in health and public health who are committed to overcoming the barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC promotes solutions that will strengthen and enhance access to adult immunization across the healthcare system. Our mission is informed by a growing body of scientific and empirical evidence that shows that immunizations improve health, protect lives against a variety of debilitating and potentially deadly conditions, and avoid costs to the healthcare system and to society as a whole. A top priority for AVAC is to achieve increased adult immunization rates through federal benchmarks and measures that encourage tracking and reporting of all recommended vaccines.

Vaccines protect us from a variety of common diseases that can be serious and even deadly. Every year, more than 50,000 adults die from vaccine preventable diseases and thousands more suffer serious health problems. Despite Advisory Committee for Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag behind the Healthy People 2020 goals for influenza, pneumococcal, Tdap, hepatitis B, herpes zoster, and human papillomavirus (HPV) vaccines. Disparities are even greater among at-risk populations, including seniors and people with chronic illness, many of the same vulnerable populations Medicare covers across the country.

Home Health Agencies (HHAs) are instrumental community providers for elderly and frail patients and have an important role to play in improving vaccine access and utilization. Home health visits provide a unique opportunity to assess the patient in their home environment and employ a multidisciplinary approach to patient care. Incorporating vaccine assessment and administration during a home health episode optimizes patient care through removal of access barriers, including transportation for homebound patients. Studies have shown that multidisciplinary healthcare providers can have a significant impact on vaccine administration rates in a home visit format. 1

The HHVBP presents an important opportunity to promote higher quality and more efficient healthcare for Medicare beneficiaries. AVAC values the opportunity to offer our comments on aspects of the proposed rule relevant to the provision of immunizations. Our coalition firmly believes that adult immunization quality measurement is central to ensuring continued focus on this core prevention intervention. We look forward to working with you to improve upon existing adult immunization quality measures and to advance new measures for current vaccines and future vaccines in the pipeline. AVAC shares your goal of building, strengthening and advancing a new generation of process and outcome measures, as outlined in the CMS Quality Strategy. We are also committed to ensuring this new generation of adult immunization measures strikes the right balance in terms of the burden on providers while ensuring the integrity and societal value of quality measurement.

AVAC believes the home health proposed rule should include a focused, concerted effort to improve access and utilization of adult immunizations as a means of improving the overall health of Medicare beneficiaries receiving home health services. Earlier this summer, 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.

The rule proposes to remove several measures, as described in Figure 4a of the CY 2016 HH PPS final rule, from the set of applicable measures, including “Influenza Vaccine Data Collection Period: Does this episode of care include any dates on or between October 1 and March 31?”; and “Reason Pneumococcal Vaccine Not Received”. The proposed rule indicates the reason for proposing to remove the influenza measure is because the data element (OASIS item M1041) is used to calculate another HHVBP measure “Influenza Immunization Received for Current Flu Season” which is proposed to be maintained in CY 2017. The proposed rule would require HHAs to report this measure annually instead of quarterly.

The proposed rule would also remove the “Reason Pneumococcal Vaccine Not Received” measure because the data are already reported as an element of the patient record for clinical decision making and inform agency policy. Additionally, the reason for the removal of individuals for whom the vaccine is not appropriate is already included in the numerator of the “Pneumococcal Polysaccharide Vaccine Ever Received”, an existing measure in the HHVBP Model. Since the influenza and pneumococcal measures are captured elsewhere through the HHVBP, AVAC is comfortable with the proposed adjustment of the 2 measures described in Figure 4 a in this context. It will be essential for home health providers to understand these adjustments which may help improve vaccine reporting.

AVAC commends CMS for maintaining under Table 31 the Influenza Immunization Received for Current Flu Season (NQF#0522) among the Population/Community Health measures for the HHVBP. The proposed rule also maintains a Pneumococcal Polysaccharide Vaccine Ever Received (NQF#0525) but would note this measure no longer reflects current recommendations of the Advisory Committee on Immunization Practices (ACIP). We urge CMS to consider including an alternative measure, Pneumonia Vaccination Status for Older Adults (NQF#0043) in the final rule. Together, these measures would represent an important baseline for access to influenza and pneumococcal vaccination services and are being utilized effectively in other settings under the Medicare program. We believe they would greatly enhance the ability of home health providers to monitor immunization status and report offered and administered influenza and pneumococcal immunizations to beneficiaries. Reducing the number of missed immunization opportunities among patients in the home health setting is critical to improving health and reducing the burden of vaccine preventable disease.

Looking ahead, the NQF report “Priority Setting for Healthcare Performance Measurement: Addressing Performance Measure Gaps for Adult Immunizations”3 noted that 60 measures have been developed to address pneumococcal immunization and that to reduce the burden and improve the value of measurement, measures should be harmonized and consolidated and “at a minimum, all measures should be up to date with current ACIP/CDC recommendations.” To that end, through its Health and Well-Being Standing Committee, NQF has proposed and approved standard specifications for pneumococcal vaccination to enable measure stewards for the existing measures (CMS and NCQA) to assess, and presumably modify, measures based on the revised standardized specifications.4 We encourage CMS to work with relevant stakeholders and quality measure organizations such as NQF to develop an updated pneumococcal immunization measure that reflects the current Advisory Committee for Immunization Practice (ACIP) recommendation for PCV13 and PPSV23 vaccination in adults age 65 and older as well as at-risk adults 19-64 years old for inclusion in the HHVBP.

AVAC is pleased that CMS is proposing to maintain two other immunization process measures in the HHVBP, “Influenza Vaccination Coverage among Healthcare Personnel” (NQF #0431) and “Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination?”. NQF#0431 is utilized effectively in a number of other healthcare settings. Moreover, leading medical and health professional associations support influenza vaccination policies for healthcare professionals to help protect patients.5 Healthcare personnel are the first line of defense when it comes to preventing illness and preserving health. Measurement tools reflecting this priority are essential to promoting health and advancing prevention in the home health setting and AVAC strongly supports the inclusion of this measure in the final rule.

We greatly appreciate that Table 31 in the proposed rule also makes herpes zoster vaccination a priority for the HHVBP. Only 28 percent of adults age 60 and older reported receiving the herpes zoster vaccine.6 Yet, the health and economic burden associated with shingles and its complications are significant. In 2007, the Agency for Healthcare Research and Quality (AHRQ) estimated the average cost of shingles and its complications to be $566 million a year while another study estimated the overall cost could be as high as $1.7 billion a year.7

Postherpetic neuralgia (PHN) is a common complication; however, other lingering and potentially severe complications and pain can have a lasting impact on an individual. AVAC urges CMS to maintain the herpes zoster vaccination process measure in the final rule. We hope that other value-based purchasing and quality reporting programs will also consider this measure in the future, particularly since the absence of zoster vaccination measures has been identified by the National Quality Forum as a significant gap in performance measurement and the development of a measure has
been identified as a priority.8

Lastly, AVAC supports under Table 33, Home Health Quality Reporting Program measures for future consideration, the proposed addition under health and well-being, the Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay). The proposed measure would fall under the NQS Patient and Caregiver Centered Care category.

Immunizations have demonstrated “effective prevention” in reducing rates of morbidity and mortality from a growing number of preventable conditions and improving overall health in a cost efficient manner. Reducing the number of missed immunization opportunities is imperative to improving health and reducing the burden of vaccine preventable illness not only among Medicare beneficiaries but also helps provide protection to grandchildren and great-grandchildren who might be too young to be immunized as well. AVAC looks forward to working with CMS to ensure that adult immunization quality measures remain an integral component of the new HHVBP and HH QRP.

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

Sincerely,

Alliance for Aging Research
American College of Preventive Medicine
Asian & Pacific Islander American Health Forum (APIAHF)
Every Child By Two (ECBT)
GlaxoSmithKline
Immunization Action Coalition (IAC)
National Association of County and City Health Officials (NACCHO)
Medicago
Merck
Novavax
The Gerontological Society of America
Trust for America’s Health