AVAC Sends Comments to CMS on the Physician Fee Schedule

AVAC asked CMS to consider several recommendations as they work to finalize changes to the Medicare Shared Savings Program (MSSP). Recommendations included: adding “Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination?” as an MSSP measure; monitoring the potential impact of new payment models such as the MSSP on access to critical preventive services, such as immunization; and adding provider and beneficiary education on the ACIP-recommended vaccines for patients with or at risk of diabetes.

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1654-P
P.O. Box 8013
Baltimore, MD 21244-8013

Re: Medicare Program: Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release; Medicare Advantage and Part D Medical Low Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model

To Whom It May Concern:

As members of the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Medicare Program Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017.

AVAC includes more than fifty organizational leaders in health and public health who are committed to overcoming the barriers to adult immunization and to raising awareness of and engaging in advocacy on the importance of adult immunization. Our mission is informed by a growing body of scientific and empirical evidence that shows that immunization improves health, protect lives against a variety of debilitating and potentially deadly conditions, and save 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 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 2 Committee on Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag behind the Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Tdap (tetanus, diphtheria, pertussis), hepatitis B, herpes zoster, HPV). Disparities are even greater for at-risk populations, including seniors and people with chronic illnesses.

The Medicare Shared Savings Program (MSSP) presents an important opportunity to promote higher quality and more efficient health care for Medicare beneficiaries. AVAC believes the CMS should engage in a focused, concerted effort to improve access and utilization of adult immunizations as a means of improving the overall health of Medicare beneficiaries. Earlier this summer AVAC released a White Paper outlining the value and imperative of quality measures for adult vaccines.1 The paper 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.

AVAC commends CMS for maintaining the Annual Influenza Vaccination (ACO#14) and the Pneumonia Vaccination Status for Older Adults measure (ACO #15) in the Medicare Shared Savings Program (MSSP’s). These measures were included under the AIM: Better Health for Populations category. Monitoring immunization status and reporting of offered and administered immunizations to patients are critical preventive service benchmarks that help to ensure immunizations remain a priority under new payment models and in the forefront of clinical care standards. Reducing the number of missed immunization opportunities, particularly among Medicare beneficiaries, is critical to improving health and reducing the burden of vaccine preventable disease.

The Annual Influenza Vaccination (ACO #14) and the Pneumonia Vaccination Status for Older Adults measure (ACO #15) are important baselines for measuring access to influenza and pneumococcal vaccination services. These two vaccine preventable conditions exact a heavy toll on adults in terms of health and productivity costs. According to the Centers for Disease Control and Prevention (CDC), an estimated 900,000 Americans get pneumococcal pneumonia each year, resulting in as many as 400,000 hospitalizations and more than 53,000 deaths. Despite the fact that most pneumococcal pneumonia deaths each year are adults, pneumococcal vaccination rates remain inadequate, with only 61.3 percent of adults over the age of 64 and 20.3 percent of high risk adults being vaccinated in 2014, a slight decrease from the previous year.2 By contrast, a recent CDC study of flu-associated deaths prevented over a nine-year period from 2005-2006 through 2013-2014 found that nearly 89 percent were in people 65 years of age and older.

AVAC encourages CMS to advance adult immunization quality measurement through the MSSP by working with relevant stakeholders and quality measure organizations 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. 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.3

AVAC would further urge CMS to consider including a core set of adult immunization quality measures that reflect the full spectrum of recommendations of the Advisory Committee on Immunization Practices (ACIP) into the MSSP in future rulemaking. Prioritizing quality measures around immunizations would help close existing measure gaps, improve upon immunization rates and health outcomes for the millions of Medicare beneficiaries. The National Quality Forum (NQF) in its August 2014 report “Priority Setting for Healthcare Performance Measurement: Addressing Performance Measures Gaps for Adult Immunizations”, highlighted ten age specific and composite measure gap priorities that should be addressed.4

The proposed rule notes that the “principal goal in selecting quality measures for ACOs has been to identify measures of success in the delivery of high-quality health care at the individual and population levels with a focus on outcomes.” The proposed rule further states that “the statute does not limit us to using endorsed measures in the Shared Savings Program.”5 As such, CMS has previously exercised discretion in including certain measures believed to be high impact but that are not currently endorsed. We would encourage CMS to consider including non-NQF endorsed adult immunization measures into the MSSP.

Specifically, AVAC would encourage CMS to consider including “Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination?” as an MSSP measure in the final rule. This non-NQF endorsed measure is presently being used under the Home Health Value-Based Purchasing Program. According to the CDC, 27.9 percent of adults age 60 and older reported receiving the herpes zoster vaccine.6 The health and economic burden associated with shingles and its complications are significant. As cited by the CDC, 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

AVAC supports a meaningful core quality measure set for current vaccines and the development of measures for vaccines in the pipeline to both 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.

However, AVAC also remains concerned that new and evolving Medicare payment models could threaten access to critical prevention services such as immunization as providers are under increased financial pressure to provide cost efficient care, particularly to medically complex and chronically ill Medicare beneficiaries. AVAC would encourage CMS to closely monitor the potential impact of new payment models such as the MSSP on access to critical preventive services, such as immunization. AVAC would like to work with CMS to explore the different payment model programs underway and lift up best practices that expand and improve access to immunization services as well as other lifesaving prevention interventions.

Lastly, under the proposed expansion of the diabetes prevention program, AVAC would strongly encourage CMS to include provider and beneficiary education on the ACIP-recommended vaccines for patients with or at risk of diabetes. Individuals with diabetes and multiple chronic conditions are at significantly higher risk of complications and death from vaccine preventable conditions such as influenza and pneumonia. According to the American Diabetes Association, people with diabetes are three times more likely to die with flu and pneumonia, yet only a third of people with diabetes receive a pneumococcal vaccination. We believe education about the benefits and risks of immunization and awareness of which vaccines are specifically recommended for individuals with diabetes will help to reduce the number of missed immunization opportunities, improve overall health and reduce the incidence and burden of vaccine preventable disease for patients who are high risk of serious and life threatening complications.

Immunization has demonstrated “effective prevention” in reducing rates of morbidity and mortality from a growing number of preventable conditions and has been proven to improve overall health in a cost efficient manner. Increasing immunization coverage rates among the Medicare population also helps provide protection across the lifespan.

Thank you for this opportunity to offer our perspective on this important 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.


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American Association of Occupational Health Nurses (AAOHN)
Dynavax Technologies
Every Child By Two
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National Association of Chain Drug Stores