Letters Archive - Page 10 of 12 - Adult Vaccine Access Coalition

AVAC Offers Comments on the Medicare Program End Stage Renal Disease (ESRD) Prospective Payment Proposed Rule

AVAC wrote to CMS to express individuals with chronic kidney disease have higher incidence or severity of some vaccine preventable diseases due to altered immunocompetence. AVAC commended CMS for allowing ESRD facilities to administer vaccines to beneficiaries with Acute Kidney Injury (AKI), asked CMS to consider including a baseline data reporting threshold for ESRD facilities for influenza, and supported the proposal to adopt a patient-level influenza immunization reporting measure that could be used to calculate a future clinical measure.

Letters to Administration

Quality Measures

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August 23, 2016

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1651-P
P.O. Box 8010
Baltimore, MD 21244-8010

To Whom It May Concern:

As members of the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Medicare Program End Stage Renal Disease (ESRD) prospective payment proposed rule.

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 Committee on Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag far 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- many of the same vulnerable populations residing in skilled nursing facilities across the country.

According to the Centers for Disease Control and Prevention (CDC), individuals with chronic kidney disease have higher incidence or severity of some vaccine preventable diseases due to altered immunocompetence. In fact, infectious disease is the second most common cause of death in late stage Chronic Kidney Disease (CKD) patients. Research has shown that kidney care centers with vaccination protocols have demonstrated reduced infection rates and resulted in decreased morbidity and mortality. Vaccines, including hepatitis B and pneumococcal conjugate and pneumococcal polysaccharide, are specifically recommended for dialysis or CKD patients. However, like with other adult populations, vaccines are underutilized in CKD patients, who could benefit greatly from improved access to immunization services. Moreover, the National Adult and Influenza Immunization Summit (NAIIS) Quality Work Group has a subgroup dedicated to the development and testing of an ESRD composite measure covering influenza, pneumoccal and hepatitis B vaccines. We believe this work provides an important foundation that will eventually allow for a comprehensive composite measure for all ACIP-recommended vaccines for ESRD patients and will be of great benefit to the ESRD QIP program in the future.

The ESRD Quality Incentive Program (ESRD QIP) presents an important opportunity to promote higher quality and more efficient health care for Medicare beneficiaries. AVAC believes the SNF QIP should include a focused, concerted effort to improve access and utilization of adult immunizations as a means of improving the overall health of patients living with kidney disease. Earlier this summer AVAC released a White Paper outlining the value and imperative of quality measures for adult vaccines. 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. Moreover, the National Adult and Influenza Immunization Summit (NAIIS) Quality Work Group has a subgroup dedicated to the development and testing of an ESRD composite measure covering influenza, pneumococcal, and hepatitis B vaccines. We believe this work will be of great benefit to the ESRD QIP program in the future.

AVAC appreciates the opportunity to respond to the request for comment on the proposal that would allow for ESRD facilities to administer vaccines to beneficiaries with Acute Kidney Injury (AKI). Specifically, ESRD facilities would be enabled to “furnish vaccines to beneficiaries with AKI and bill Medicare in accordance with billing requirements in Pub. 100–04, Chapter 18 Preventive and Screening Services, section 10.2”. This section of the Medicare claims processing manual sets forth billing requirements for influenza, pneumococcal and hepatitis B vaccination. These vaccines are recommended by the Advisory Committee on Immunization Practices (ACIP) for patients with kidney disease since they are particularly vulnerable to serious and potentially life-threatening complications from these vaccine-preventable conditions. Encouraging ESRD facilities to offer and administer vaccines to AKI patients is important to reducing the number of missed immunization opportunities and improving vaccine coverage rates for this population. We strongly support this proposal and urge CMS to maintain it in the final rule.

The proposed rule would also maintain the National Healthcare Safety Network (NHSN) Healthcare Provider Influenza Vaccination reporting measure (79 FR 66209). AVAC supports maintaining this measure into PY 2020. We would note, however, that Table 11 in the proposed rule indicates there is no minimum data reporting requirement for the measure. HHS urges healthcare facilities to work toward the goal of 90 percent influenza vaccination coverage for healthcare personnel. We would urge CMS to consider including a baseline reporting threshold for ESRD facilities similar to what is required for inpatient rehab hospitals and other healthcare facilities.

Section IV of the proposed rule recommends a series of quality improvement initiatives for the ESRD program. Included is a proposal in PY 2019 to adopt a patient-level influenza immunization reporting measure that could be used to calculate a future clinical measure based on either ‘‘ESRD Vaccination—Full Season Influenza Vaccination’’ (MAP #XDEFM) or NQF #0226: ‘‘Influenza Immunization in the ESRD Population (Facility Level).’’ AVAC supports this step and urges CMS to consider including reporting measures for pneumococcal and hepatitis B vaccination and urges CMS to move swiftly to include patient level reporting for influenza and other ACIP-recommended vaccines into the ESRD QIP.

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. Reducing the number of missed immunization opportunities is critical to improving health and reducing the burden of vaccine-preventable illness among the ESRD population.

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.

Sincerely,
Alliance for Aging Research
American Association of Occupational Health Nurses (AAOHN)
American College of Preventive Medicine
Asian & Pacific Islander American Health Forum (APIAHF)
Dynavax Technologies
Immunization Action Coalition (IAC)
Medicago
National Association of County and City Health Officials (NACCHO)
National Foundation for Infectious Diseases (NFID)
National Hispanic Medical Association
National Viral Hepatitis Roundtable
Takeda Vaccines
The Gerontological Society of America
Trust for America’s Health

AVAC Responds to Proposed Changes to Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive

AVAC sent comments to CMS on proposed changes to the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentive program. AVAC explained to CMS how an adult immunization quality measurement and the three core strategies in the proposed rule can drive improved adult immunization coverage rates by: 1) Improving the way clinicians are paid to incentivize quality and value of care over simply quantity of services; 2) improving the way care is delivered by providing clinical practice support, data and feedback reports to guide improvement and better decision-making and; 3) making data more available in real-time at the point of contact and enabling the use of certified EHR technology and other data sources to support care delivery. AVAC also made comments on specific parts of their proposal.

Letters to Administration

Quality Measures Supporting Providers Vaccine Infrastructure

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June 27, 2016

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-5517-P
P.O. Box 8013

RE: Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models

To Whom It May Concern:

AVAC appreciates the opportunity to offer comments in response to the Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. As a stakeholder interested in advancing new physician payment models that encourage access to essential preventive services such as immunization, we are grateful to CMS for its work in this area.

AVAC consists of 50 organizational leaders in health and public health who are committed to tackling the range of barriers to adult immunization and to raising awareness of its importance. 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. 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 Committee for Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag far behind the Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Tdap, hepatitis B, herpes zoster, human papillomavirus vaccine (HPV)). 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.

The MACRA rule represents a significant step in the transition of Medicare physician payments away from a volume-based model to a system that incentivizes and rewards value. The stated goal of the proposed rule is to, “…improve physician payments by changing the way Medicare incorporates quality measurement into payments and by developing new policies to address and incentivize participation in alternative payment models.”1

The proposed rule seeks to establish the Merit-Based Incentive Payment System (MIPS), consolidating three existing quality and performance measure programs – Physician Quality Reporting System (PQRS), the Physician Value-based Modifier (VM) and the Medicare Electronic Health Record (EHR) Incentive Program — and establish incentives for participation in certain alternative payment models (APMs). Within MIPS, the proposed rule outlines measures, activities, reporting and data submission standards across the four new performance categories that together will comprise the MIPS composite performance score.

AVAC values the opportunity to offer our comments on aspects of each performance category relevant to the provision of immunizations as well as our view on other related aspects of the proposed rule. 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 toward improving upon existing adult immunization quality measures. 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 that adult immunization quality measurement and the three core strategies underlying the foundation for progress toward a truly patient-centered health care delivery system in the proposed rule can also help drive improved adult immunization coverage rates by: 1) Improving the way clinicians are paid to incentivize quality and value of care over simply quantity of services; 2) improving the way care is delivered by providing clinical practice support, data and feedback reports to guide improvement and better decision-making and; 3) making data more available in real-time at the point of contact and enabling the use of certified EHR technology and other data sources to support care delivery.

Quality

The proposed rule calls for the new quality performance category to reflect many of the attributes of the PQRS program while also providing some flexibility. For 2019, the quality performance category would account for 50 percent of a clinician’s composite performance score (CPS), thereby representing a significant portion of their ultimate payment under MIPS. The measures ultimately selected under the quality performance category will have major implications in terms of clinicians’ delivery of care. The proposed rule specifies that from the list of possible measures, clinicians must report on a minimum of six measures, including one cross-cutting measure and an outcome measure (or another priority measure such as appropriate use, patient safety, efficiency, patient experience or care coordination if an outcome measure is not available). Clinicians may choose from the individual or specialty-specific measure sets outlined in the proposed rule. With that in mind, AVAC would like to offer the following comments:

Cross-cutting Measures

“Cross-cutting measures help focus our efforts on population health improvement.” As recognized in Healthy People 2020, prevention of infectious disease through immunization is a key factor in improving the health of our nation.

The proposed rule recommends that the following immunization-related cross-cutting measures not continue for 2017: PQRS #110 (Preventive Care and Screening: Influenza Immunization), PQRS #111 (Pneumonia Vaccination Status for Older Adults) and PQRS #240 (Childhood Immunization Status). AVAC has deep concerns with this proposal and its potential impact on the provision of and access to immunization services for Medicare beneficiaries.

It is imperative that elderly and disabled patients have access to ACIP-recommended vaccines through their main provider, which in the case of chronically ill beneficiaries, could be a specialist such as an endocrinologist, a cardiologist or another member of the patient’s healthcare team. The rationale applied to eliminate some of the cross cutting measures, “the reporting MIPS eligible clinician may not actually be providing the care, but are just reporting another MIPS eligible clinician’s performance result” does not apply to either of these vaccine measures as the first step is to screen for immunization.

Screening should be done by the main providers to ensure that each individual is counseled and has the opportunity to receive the appropriate immunizations. Removing PQRS #110 and PQRS #111 as cross-cutting measures would significantly reduce the likelihood that eligible professionals in a variety of care settings will be incentivized to offer immunization services in the course of providing care to patients. Published literature indicates that fewer providers offering these critical prevention services will result in more ‘missed opportunities’ for immunization and a greater likelihood of illness and complications from vaccine preventable conditions such as influenza and pneumonia. The National Vaccine Advisory Committee’s (NVAC) Adult Immunization Standards call for all providers caring for adult patients to assess, recommend, vaccinate or refer, and document vaccinations.2

Individual Quality Measures AVAC appreciates that the proposed rule maintains a majority of PQRS measures for the first year of MIPS, including several important, immunization-related process measures. All of these measures fall under the Community/Population Health domain of the National Quality Strategy.

NQF #0041 PQRS #110 Preventive Care and Screening: Influenza Immunization. Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.

NQF #0043/PQRS #111 Pneumonia Vaccination Status for Older Adults. Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

NQF #1407/PQRS #394 Immunizations for Adolescents. The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.

In terms of the aforementioned individual measures, AVAC would strongly recommend that NQF #0041 and #0043 be characterized as high priority and core measures. Prioritizing these measures will expand the number of clinicians utilizing them and produce increased adult immunization rates in the U.S. We also recommend that CMS work to broaden the scope of the adult immunization measures included under quality performance category, to include other ACIP-recommended vaccines, such as Tdap and Zoster, as well as immunization measures for special populations at greater risk of vaccine preventable disease (e.g., people with diabetes, high-risk populations over 50).

We encourage CMS to streamline the quality measure development process for new vaccines to ensure more timely alignment with FDA approval and ACIP recommendations. Reducing delays in the adoption of accurate measures will result in improved uptake and utilization of adult vaccines across healthcare settings.

AVAC is concerned that the following measure is proposed to be removed:

Hepatitis C: Hepatitis A Vaccination. Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A. In light of the health and economic burden hepatitis C represents for millions of Americans, proposing to remove a measure that would help protect the health of these patients from other vaccine preventable conditions seems like a step in the wrong direction. We disagree with the proposed rule’s assessment that the “measure is considered low-bar and not robust enough to stand alone.”

The proposed rule offers a number of quality measures under specialty measure sets. AVAC is encouraged to see that the following specialty sets include immunization related process quality measures:

Allergy/Immunology/Rheumatology. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults

General Practice/Family Medicine. NQF # 1407 Immunizations for Adolescents

Pediatrics. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF #0038 Childhood Immunization Status

Preventive Medicine. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults

AVAC was, however, disappointed that the proposed rule did not include quality measures aimed at patients at greater risk of serious complications from vaccine preventable illness. In particular, please note that the ACIP includes age-based as well as condition-specific recommendations for adult vaccination. For instance, patients living with chronic illnesses such as heart disease and diabetes are at a significantly higher risk of complications and death from influenza and pneumonia. The CDC has reported that in 2013 only 21.2% of adults in this group had received a pneumococcal vaccination, and this number has been essentially unchanged for at least a decade.3

Additionally, individuals with diabetes are at increased risk for hepatitis B infection. As such, the ACIP recommends hepatitis B vaccination for all patients with diabetes age 604 and under as well as other at risk patients, such as those living with HIV/AIDS and chronic kidney disease. We strongly encourage CMS to add this measure into the individual and specialty measure sets.

AVAC would also urge CMS to, at a minimum, include the following measures under the following specialty measure sets:

Internal Medicine. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults.

Endocrinology. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults.

Cardiology. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults.

Obstetrics/Gynecology. NQF# 0041 Preventive Care and Screening: Influenza Immunization.

The proposed rule notes that Section 1848(q)(2)(C)(ii) of the Act allows the Secretary to use measures from other CMS payment systems, such as measures for inpatient hospitals, for purposes of the quality and resource use performance categories. AVAC urges CMS to look broadly across payment systems under its purview and incorporate a broad array of relevant adult immunization quality measures from other clinical settings, such as the Herpes Zoster (Shingles) vaccination process measure being advanced under the home health value-based payment program – Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination?

AVAC appreciates that eligible clinicians have the ability to submit quality performance data through a variety of means, including claims, QCDR, a qualified registry, EHR, or automatically through administrative claims.

Innovation Center Quality Measure Review Process

AVAC is pleased that the proposed rule seeks to establish an Innovation Center quality measure review process for those measures that are not NQF-endorsed or included on the final MIPS measure list to assess if the quality measures have an evidence-based focus, and are reliable and valid. We would encourage CMS to consider prioritizing a broader set of recommended immunization measures as part of the Innovation Center’s quality measure review process. We ask that CMS work with relevant stakeholders to develop, test, and integrate additional ACIP-recommended adult immunizations into quality measure and incentive benchmarks under MIPS.

Moving forward, AVAC believes that important work is currently underway to develop and test comprehensive, composite measures for adults5 that could bring greater flexibility and more complete information regarding the immunization status of an adult as ACIP-recommendations evolve and change, similar to what pediatric and family providers currently use to measure childhood immunization status.

AVAC encourages CMS to prioritize the development of adult immunization quality measures and include them in future updates. The National Quality Forum in their August 2014 report, “Priority Setting for Healthcare Performance Measurement: Addressing Performance Measure Gaps for Adult Immunizations”6 identifies several age specific and composite measure sets for adult immunization that would help address current gaps in immunization and reduce the number of missed opportunities to vaccinate patients with the greatest need. Moreover, a number of promising new vaccines in late stage development have great potential to save lives and reduce healthcare costs. Yet, delays in the development and implementation of quality measures can have a detrimental impact on immunization rates. Therefore, we would encourage CMS to streamline the quality measure development process once a vaccine for the Medicare population receives both FDA approval and a recommendation by the ACIP.

Clinical Practice Improvement Activity (CPIA)

AVAC supports the goal of the Clinical Practice Improvement Activity (CPIA performance category to, “use a patient-centered approach to program development that leads to better, smarter and healthier care.”7 A number of adult immunization performance improvement activities are evidence-based, are feasible to implement, are linked to continuous improvement over time, result in improved health outcomes, are linked to population health management, align with the requirements of a patient-centered medical home, and can promote health equity. While the CPIA performance category only accounts for 15 percent of the composite performance score, it is an important new element that will drive improvements in care over the long-term. AVAC encourages CMS to consider and prioritize CPIAs that will lead to improved adult immunization rates and overall health outcomes, and will encourage provider alignment with the NVAC Adult Immunization Standards.

Advancing Care Information (ACI)

The proposed rule seeks to transition the meaningful use of certified EHR technology to the new advancing care information performance category. The proposed rule provides accommodations to ensure that clinicians who are at different stages of meaningful use are able to participate in the advancing care information performance category while also recognizing that not all providers in all states have the ability to report immunization record data to an Immunization Information System (IIS). Although immunizations are often administered in a clinical setting, a patient’s lifetime immunization record will span decades, and the consolidation of records as individuals move among health care providers is a uniquely public health function. It is this consolidated record that drives the accurate forecast of immunizations due, and past due, at the point of care. For this reason, seamless multidirectional interoperability between CEHRT and Public Health in general, and IIS in particular, is essential to ensure the provision of appropriate clinical services, and a precursor for accurate measurement of quality care.

In terms of immunization, AVAC was pleased to note that the advancing care information category incentivizes the continued participation of clinicians in state and local immunization information systems. Specifically, to earn the full base score points, a MIPS eligible clinician would only need to complete submission on the Immunization Registry Reporting measure of this objective. Completing any additional measures under this objective would earn one additional bonus point in the advancing care information performance category score.

In addition to reporting to state Immunization Information Systems (IIS), we urge that the ACI incentivize and encourage the following: sending reminders to patients using certified EHRs; sending educational information to patients using EHRs; implementing clinical decision support (CDS) tools to identify patients requiring vaccines; EHR generation of patient lists requiring immunizations; use of ePrescribing technology to implement electronic, two-way communication between the vaccine-recommending clinician’s chart and that of the vaccinating provider, accomplishing health information exchange (HIE) and the exchange and access to data between immunization providers within the immunization neighborhood. All of these EHR functionalities will strongly promote immunization and assist busy clinicians in assessing, recommending, providing/ referring for, and documenting immunizations –the four call-to-actions in the revised Standards for Adult Immunization Practice8. Incorporating these functions will facilitate the implementation of technology that exists today but is not fully utilized—and stands as a barrier to increased adult immunization— including IIS reporting and two-way exchange of data between referring clinicians and vaccinating providers in complementary settings, such as pharmacies, hospitals, and health departments.

Moreover, the proposed rule differentiates the Immunization Registry Reporting Measure between active engagement under Stage 2 and Stage 3 reporting. AVAC appreciates that the proposed rule strongly encourages the reporting of immunization data and continues to advance efforts to provide for multidirectional data exchange. Immunization forecasts and patient histories are important tools that strengthen and enhance the ability of clinicians to educate patients and improve clinical decision making at the point of care.

Lastly, an additional area where greater reporting and interoperability would be of benefit is in support of vaccine management in private and public health care settings. EHR-IIS interoperability is essential to stronger and more efficient vaccine supply management through providing vaccine ordering, inventory, and accountability functions in clinical care settings, both during routine provision of immunizations and in cases of disease outbreaks.

Resource Use

The proposed rule would continue two measures currently employed under the value-based modifier – total per capita costs for all attributed beneficiaries and Medicare Spending per Beneficiary.

While AVAC appreciates that the measures account for risk factors such as socioeconomic and demographic characteristics, ethnicity and individual health status, we would also urge CMS to carefully consider the overall impact of the resource use measure on immunization services. We understand CMS plans to review recommendations from the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) on the issue of risk adjustment for socioeconomic status to ensure that clinicians who care for a disproportionate number of low-income beneficiaries are not inadvertently disadvantaged under the resource use calculation relative to their counterparts. It is also important to understand the unique and relatively complex nature of immunization services for clinicians. Many struggle with storage, inventory, and payment hurdles for vaccines. Managing all of these aspects under a capitated arrangement can actually result in declines in vaccine utilization.

The proposed rule indicates that in measuring resource use, “the Secretary shall use the per patient total allowed charges for all services under Medicare Part A and B but also provides discretion to also include Part D, as appropriate.” AVAC strongly believes that patients should be able to receive all recommended vaccines in their preferred healthcare setting. Our coalition urges CMS to improve billing systems for providers administering Part D vaccines. However, should Part D become part of the resource use performance component, we urge you to exclude Part D vaccine costs so as not to disincentivize clinicians who wish to offer the full complement of ACIP recommended vaccines to patients. In addition, providers should be incentivized to collaborate with other healthcare providers who can efficiently provide immunization services, increase patient access and achieve patient completion of vaccination series. In regards to immunizations, aligned incentives and policy should encourage provider collaboration, coordination and communication – all tenets of the immunization neighborhood.

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 among Medicare beneficiaries. AVAC looks forward to working with CMS to ensure that adult immunization quality measures remain an integral component of the new MIPS and are a focus of certain Alternative Payment Models (APMs) in the coming years as well.

Thank you for this opportunity to offer our perspective on this rule being considered. 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,

American College of Preventive Medicine (ACPM)
American Pharmacists Association
Asian Pacific Islander American Health Forum (APIAHF)
Biotechnology Innovation Organization (BIO)
Dynavax
GSK
Hep B United
Hepatitis B Foundation
Immunization Action Coalition (IAC)
Infectious Diseases Society of America (IDSA)
Merck
National Association of County and City Health Officials (NACCHO)
National Association of Chain Drug Stores (NACDS)
National Foundation for Infectious Diseases
Novavax
Pfizer
Sanofi
Takeda Pharmaceuticals
The Gerontological Society of America
Trust for America’s Health

AVAC Comments on Skilled Nursing Facilities Quality Reporting Program Proposed Rule

The Skilled Nursing Facility Quality Reporting Program (SNF QRP) presents an important opportunity to promote higher quality and more efficient health care for Medicare beneficiaries. AVAC wrote to CMS to explain why the SNF QRP should include a focused, concerted approach to adult immunizations as a means of improving the health of patients living in skilled nursing facilities.

Letters to Administration

Quality Measures

Download

June 20, 2016

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1645-P
P.O. Box 8016
Baltimore, MD 21244-8016

Re: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities Proposed Rule for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research

To Whom It May Concern:

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Medicare Program proposed rule on the SNF Quality Reporting Program.

AVAC consists of over forty-five organizational leaders in health and public health that are committed to tackling the range of 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 of the benefits of immunization through 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. 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 Committee for Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag far behind the Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Tdap, hepatitis B, herpes zoster, HPV). Disparities are even greater when looking at-risk populations, including seniors and people with chronic illness- many of the same vulnerable populations residing in skilled nursing facilities across the country.

The Skilled Nursing Facility Quality Reporting Program (SNF QRP) presents an important opportunity to promote higher quality and more efficient health care for Medicare beneficiaries. AVAC believes the SNF QRP should include a focused, concerted approach to adult immunizations as a means of improving the health of patients living in skilled nursing facilities.

AVAC appreciates the opportunity to respond to the request for comment on the importance, relevance, appropriateness, and applicability for each of the quality measures in “Table 13” SNF QPR Quality Measures under consideration for future years. We support the development of a measure related to the IMPACT Act domain, as well as accurately communicating the existence of and providing for the transfer of health information and care preferences of an individual to the individual, family caregiver of the individual, and providers of services furnishing items and services to the individual, when the individual transitions. We support the addition of the National Quality Strategy Priority Measure related to health and well-being, Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine.

We further encourage CMS to consider prioritizing a broader set of recommended immunization measures as part of the SNF QRP. In this vein, we ask that CMS work with relevant stakeholders to develop, test, and integrate additional ACIP-recommended adult immunizations into quality measure and incentive benchmarks under Medicare SNF QRP Quality Measures. 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. Reducing the number of missed immunization opportunities is imperative to improving health and reducing the burden of vaccine preventable illness among the skilled nursing population.

Thank you for this opportunity to offer our perspective on this rule being considered. 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,

American College of Preventive Medicine
Asian Pacific Islander American Health Forum
Dynavax
Gerontological Society of America
Immunization Action Coalition
National Association of County and City Health Officials
Sanofi
Takeda
Trust for America’s Health

AVAC Expresses Support for Maintaining the Influenza Immunization Measure

AVAC commented on CMS’s Medicare Program Hospital Inpatient Prospective Payment proposed rule because preventing transmission of influenza and other infectious agents within inpatient healthcare settings requires a multi-faceted approach since the spread of influenza can occur among patients, Health Care Professionals (HCP), and visitors. Required measures through the Medicare hospital inpatient program play a critical role in promoting improved care quality facilitating adherence to the influenza vaccine.

Letters to Administration

Quality Measures

Download

June 17, 2016

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1655-P
P.O. Box 8016
Baltimore, MD 21244-8016

RE: CMS–1655–P Medicare Program proposed rule on Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; and Technical Changes Relating to Costs to Organizations and Medicare Cost Reports.

To Whom It May Concern:

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Medicare Program Hospital Inpatient Prospective Payment proposed rule.

AVAC consists of organizational leaders in health and public health that are committed to tackling the range of 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 of the benefits of immunization through 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.

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. Immunization quality measures are a crucial tool for health care quality improvement and have demonstrated effectiveness in increasing immunization rates.

Preventing transmission of influenza and other infectious agents within inpatient healthcare settings requires a multi-faceted approach since the spread of influenza can occur among patients, Health Care Professionals (HCP), and visitors. Required measures through the Medicare hospital inpatient program play a critical role in promoting improved care quality facilitating adherence to the influenza vaccine.

VBP Program. In FY 2018, CMS removed NQF#1659 IMM-2, the Influenza Immunization Measure, from the Hospital VBP Program. AVAC urges CMS to once again include this important measure as part of the Hospital VBP program. The Advisory Committee on Immunization Practices (ACIP) recommends an annual influenza vaccination for all people age 6 months or older. Each year, influenza causes approximately 200,000 hospitalizations and 36,000 deaths in the United States. It also costs the United States about $16 billion annually to treat this vaccine-preventable disease among US adults 50 or over. Having IMM-2 as part of the VBP Program will help increase access and utilization of this important vaccine by ensuring that healthcare providers offer recommended vaccines to their patients.

IQR. We support the proposal to maintain IMM-2 (NQF #1659) as part of the Hospital Inpatient Quality Reporting (IQR) program for FY 2019 and subsequent years. This measure plays a critical role in the CMS Quality Strategy as well as the National Quality Strategy in terms of influenza immunization efforts.

Data Stratification. AVAC coalition members are working on projects that seek to identify and enhance our understanding of coverage gaps and are developing pilot programs to test targeted solutions where these disparities currently exist. We support the idea of future stratification of Hospital IQR Program data by race, ethnicity, sex, and disability on Hospital Compare, as well as on potential future hospital quality measures that incorporate health equity. Additionally, we recommend that the data also be stratified by primary language. Together, this type of data will enable more accurate evaluation in coverage gaps and disparities, particularly among minority and vulnerable populations, and are essential to improving the impact of adult immunization efforts and expanding coverage.

New Measures. We value your request for comment on potential new quality measures under consideration for future inclusion in the Hospital IQR Program. While we do not wish to specifically comment on the three new measures proposed, we would like to call attention to the importance of all ACIP recommended vaccinations. The 2014 National Healthcare Quality and Disparities Report by the Agency for Health Care Research and Quality (AHRQ) found that publicly-reported CMS measures were much more feasible than measures reported by other sources to stimulate high levels of performance. Additionally, CMS’ Quality Improvement Network Quality Improvement Organization (QIN-QIO) 11th Scope of Work (SOW) includes strategies aimed at improving reporting of all adult immunizations and increasing immunization rates among the Medicare population.

In this vein, we would like for CMS to revisit the elimination of the IMM-1 (Pneumococcal Immunization -NQF #1653) from the Hospital IQR Program in FY2016 for the FY 2018 payment determination and in subsequent years. Pneumonia is responsible for over a million hospitalizations and 50,000 deaths each year in the United States. Vaccines are an effective intervention against the high cost of medical care and rates of preventable death associated with this disease, particularly among medically vulnerable populations and the elderly. That is why the 2014 Advisory Committee for Immunization Practices (ACIP) recommendations call for adults aged 65 years or older and individuals with underlying immunocompromising health conditions between 19 and 64 years of age to receive PCV13 and PPSV23. ACIP also recommends PPSV23 for adults 19 through 64 years of age with underlying chronic health conditions like diabetes, heart disease, liver disease or lung disease (including people who smoke or have asthma). We strongly encourage CMS to prioritize adding the pneumococcal immunization measurement back into the Hospital IQR program.

Public Display of Measures.

Preventing transmission of influenza virus within healthcare settings requires a multi-faceted approach. We see surveillance as a key component in prevention and management of influenza outbreaks. We agree that LTCH QRP data should be publicly available on a CMS website, such as Hospital Compare. Specifically, we support your proposal to publicly report in CY 2017, pending the availability of data, on facility-wide influenza vaccination coverage among Healthcare Personnel (NQF #0431). Recent studies have suggested that vaccination of nursing home staff members may reduce the incidence of influenza among nursing home residents. Current national estimates of employee vaccination rates (around 50%) indicate that residents may be at an unnecessarily high risk of contracting influenza1,2. Tracking vaccine status among health care workers has the ability to increase vaccination rates and reduce absenteeism among healthcare personnel.

Additionally, we support the public reporting of data around the “Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680).” As influenza vaccines can be accessed through multiple settings, we support the suggested proposal that criteria be based on patients who 1) receive the influenza vaccine during the influenza season; 2) are offered and declined the influenza vaccine; and 3) who are ineligible for the influenza vaccine due to contraindication(s).

Please contact an 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,

American College of Preventive Medicine
Asian Pacific Islander American Health Forum
BIO
Dynavax
Gerontological Society of America
GSK
Immunization Action Coalition
National Association of County and City Health Officials
Pfizer
Sanofi
Takeda
Trust for Americas Health

AVAC Answers Questions Regarding Assessing Interoperability for MACRA

AVAC offered comments in response to the Office of the National Coordinator for Health Information Technology (ONC) request for information on interoperability. The ONC metrics for measuring and certifying interoperable health information presents a critical opportunity to improve and clarify standards for interoperability between certified electronic health records and Immunization Information Systems (IIS). AVAC strongly believes that interoperability between immunization providers and state and local IIS is well within our reach and has the potential to facilitate greater utilization of ACIP recommended adult immunizations.

Letters to Administration

Vaccine Infrastructure

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To Whom It May Concern:

AVAC appreciates the opportunity to offer comments in response to the Office of the National Coordinator for Health Information Technology (ONC); Medicare Access and CHIP Reauthorization Act of 2015; Request for Information Regarding Assessing Interoperability for MACRA. As a stakeholder interested in the goal of interoperability, we are grateful to ONC for its work in this area.

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 improve reporting of adult vaccination data to state and jurisdictional immunization information systems (IIS) and to encourage greater integration and interoperability of health information technology to enhance the exchange adult immunization data. We believe these efforts will result in more complete and timely information regarding an adult’s vaccination status that will improve patient care and health outcomes.

Near universal access to immunizations for children has been one of the greatest public health accomplishments of the 20th century. However, despite Advisory Committee for Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag far behind the Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Tdap, HepB, herpes zoster, HPV). The Adult Vaccine Access Coalition (AVAC) is working to raise awareness, improve access, and increase utilization of vaccines among adults. Every year, more than 50,000 adults die from vaccine preventable diseases and thousands more suffer serious health problems that cause them to miss work and leave them unable to care for those who depend on them.

IIS systems, also known as registries, are confidential, population-based, computerized systems that have the power to provide timely information to providers at the point of care about recommended vaccines for the adult population and foster their ability to receive and send information about a patient’s immunization status. At the population level, an IIS can also provide aggregate data on immunizations for use in surveillance and program operations, and guide essential public health activities and decision making.

Despite widespread availability of state and jurisdictional IIS’ and their frequent use by pediatric providers, only 32 percent of adults 18 and over have immunization records in an IIS.1 While thirty-six IIS programs have the authority to transmit or allow access to immunization data across state borders, only eleven are currently exchanging information directly with another IIS using batch files or bidirectional real-time exchange.2 Advancements in technology create multiple opportunities for greater access and utilization of immunizations among adults. To be a truly useful tool, immunization registries must receive and contain data that is timely, accurate, and complete.

The ONC metrics for measuring and certifying interoperable health information presents a critical opportunity to improve and clarify standards for interoperability between certified electronic health records and IIS’. AVAC strongly believes that interoperability between immunization providers and state and local IIS is well within our reach and has the potential to facilitate greater utilization of ACIP recommended adult immunizations.

Scope of Measurement: Defining Interoperability and Population

Our goal of improving access to and utilization of ACIP-recommended adult vaccines aligns closely with ONC’s efforts to assess the extent to which ‘meaningful EHR users’ are electronically sending, receiving, finding and integrating information that has been received within an EHR. A number of public and private stakeholders, including ONC, are engaged in complementary efforts to break down technological and geographical barriers to more timely and complete reporting of immunization encounters into state and jurisdictional IIS’, as well as enhance immunization provider access to real-time data on a patient’s immunization status to inform education and support clinical decision making.

Question: Should the focus of measurement be limited to ‘‘meaningful EHR users,’’ as defined in this section and their exchange partners? Alternatively, should the populations and measures be consistent with how ONC plans to measure interoperability for the assessing progress related to the Interoperability Roadmap?

AVAC supports building on the work and accomplishments of the CMS Medicare and Medicaid EHR incentive program in terms of encouraging greater reporting and bidirectional exchange between “meaningful EHR users” and their exchange partners, which would be other immunizers (eg. pharmacy and employer-sponsored health clinics) and state and jurisdictional IIS’. It is however, important to work towards broader alignment with ONC plans to measure interoperability in accordance with the standards for progress included in the Roadmap. Immunization opportunities can occur in a wide variety of health care settings, including Medicare beneficiaries who might be receiving home health care or residing in a long-term care facility as well as individuals who receive immunization services from public health clinics. For the chronically ill elderly and disabled, being up to date on recommended immunizations can be critical to overall health and wellbeing. Reporting of immunization encounters and access to up-to-date immunization records is particularly important in these settings to avoid missed opportunities to immunize and ensure that a patient is not receiving redundant vaccines as well.

Question: How should eligible professionals under the Merit-Based Incentive Payment System (MIPS) and eligible professionals who participate in the alternative payment models (APMs) be addressed?

Please refer to attachment #1, the AVAC comment letter in response to CMS-3321-NC Request for Information (RFI) regarding implementation of the Merit-based Incentive Payment System, Promotion of Alternative Payment Models and Incentive Payments for Participation in Eligible Alternative Payment Models.

Question: ONC seeks to measure various aspects of interoperability. Do these aspects of interoperability adequately address both the exchange and use components of section 106(b)(1) of the MACRA?

The RFI indicates that ONC seeks to measure the electronic sending, receiving and finding, integrating of information received into a patient’s medical record and subsequent use of the information received from outside sources as well as the use of information received for clinical decision-making. Achieving bidirectional exchange of immunization information across the range of community immunizers and IIS’ consistently across providers, health care settings and states would go a long way toward improving adult immunization rates. It would enable providers to communicate and share immunization information via the IIS as well as enable providers to have access to accurate and complete immunization records in order to provide patient education and help inform clinical decision-making. In order for that to happen, however, IIS’, EHRs and providers need to continue working to standardize the transmission of bidirectional information consistently.

Measures Based Upon National Survey Data

The RFI indicates that ONC is considering measures based on national survey data for hospitals and office-based physicians that would track the proportion of healthcare providers who are sending, receiving and finding, integrating key health information; use information received electronically from outside providers and sources for clinical decision-making; and who electronically perform reconciliation of clinical information. AVAC views all of these measures to be very important in the context of adult immunization and urge ONC to make immunization a foundational element of the measure development process.

Question: Do the survey-based measures described, which focus on measurement from a health care provider perspective adequately address the two components of interoperability as described in section 106(b)(1) of MACRA?

Both the AHA Health IT Supplement Survey and the National Electronic Health Record Survey of office-based physicians referenced in the RFI include a question on whether or not a computerized system is available to submit electronic data to immunization registries/information systems. In addition, the AHA Health IT Supplement survey includes questions regarding technical capability to send and receive patient health information with outside providers and sources. We believe these questions can provide important information regarding barriers to bidirectional exchange.

Question: Could office-based physicians serve as adequate proxies for eligible professionals who are “meaningful EHR users” under the Medicare and Medicaid EHR Incentive Programs?

We would urge ONC to explore other survey opportunities that would more directly capture the participation of “meaningful EHR users” across the broader health care workforce in terms of providers and health care settings. We also would encourage ONC to engage other outside providers and public health stakeholders, including pharmacy organizations as well as entities involved in the development, implementation and management or IIS’ in order to development measurement tools that will capture a complete picture of progress around IIS/EHR interoperability.

Question: Do national surveys provide the necessary information to determine why electronic health information may not be widely exchanged? Are there other recommended methods that ONC could use to obtain this information?

AVAC consists of a wide range of organizations representing providers, public health, minority health organizations, patient groups, vaccine innovators and immunization registry organizations. As such, we would encourage ONC to also engage directly with individual organizations since many conduct regular surveys of their membership to solicit feedback on concerns and challenges in their respective fields. Specifically, the Pharmacy Quality Alliance (PQA) is working to develop measures focused on administered vaccines and IIS reporting that could be beneficial to ONC. Many of our member organizations also have knowledge and understanding of barriers preventing the wide exchange of electronic health information.

CMS Medicare and Medicaid EHR Incentive Programs Measures

The RFI notes that ONC is considering using the proportion of transitions or care or referrals as a measure to evaluate the exchange and use aspects of interoperability under the following circumstances: where a record was created using certified EHR technology and exchanged/transmitted electronically; where a new provider receives, requests or queries a summary of care document to incorporate into the patient’s record; where a medication reconciliation is performed; and where a new provider receives a transition or referral and performs a clinical information reconciliation for medications, medication allergies and problem lists.

Question: Given the limitations described, do these potential measures adequately address the “exchange” component of interoperability?

As the RFI indicates, while proposed system would capture individual eligible professionals, hospitals and CAH’s under Medicare, it would not be able to do the same for Medicaid providers. Additionally, it would ensure a summary of care was sent but does not have the ability to assess whether a summary of care was electronically received. AVAC would note that the summary of care documents used to meet the meaningful use objective must include immunizations among the information provided. While the summary of care helps to provide a least part of a patient’s immunization record, it may not present the entire picture. We would encourage ONC to consider including the exchange of immunization record data to and from IIS’ systems among the possible measures of interoperability.

Question: Do the reconciliation-related measures serve as adequate proxies to assess the subsequent use of exchanged information? What alternative national-level measures should ONC consider for assessing this specific aspect of interoperability?

As noted earlier, AVAC would encourage ONC to consider including the exchange of immunization record data from IIS’ among the measures of interoperability. While a summary of care from a provider might contain some of a patient’s immunization history, directly querying and receiving information from an IIS’ would potentially reveal additional immunizations a patient may have received in health care settings outside of a provider’s office.

Question: Can state Medicaid agencies share health care provider level data with CMS similar to how Medicare currently collects and reports on these data in order to report on progress toward widespread health information exchange and use? If not, what are the barriers to doing so? What are some alternatives?

Medicaid is a federal-state partnership and as such Medicaid agencies run independently from one another. Given this variability, it would seem that getting standardized health care provider level data similar to what Medicare currently collects and reports would be a significant challenge. It could take many years to get the appropriate systems in place to allow for such reporting by Medicaid providers.

Identifying Other Data Sources to Measure Interoperability

Question: Should ONC select measures from a single data source for consistency, or should ONC leverage a variety of data sources? If the latter, would a combination of measures from CMS EHR Incentive Programs and national survey data of hospitals and physicians be appropriate?

From the standpoint of immunization, the CMS EHR Incentive Programs and national survey data of hospitals and physicians provide a solid foundation of measurement for immunization upon which ONC can build as time goes on. These two data sources have long prioritized immunization reporting and their processes are ones with which eligible providers are comfortable.

Question: If ONC seeks to limit the number of measures selected, which are the highest priority measures to include?

AVAC would strongly encourage ONC to maintain reporting of immunization record data and the bidirectional exchange of this information among the foundational measures included for interoperability. The Medicare and Medicaid EHR Incentive and the ONC Meaningful Use program has made bidirectional exchange between provider EHR systems and IIS’ a top priority. This emphasis has been essential to driving public-private collaborations to achieve consensus on standards3 as well as inspiring local technology solutions to discreet barriers to interoperability. This also supports NVAC’s Adult Immunization Standards that call for any provider of adult immunizations to assess immunization status, recommend appropriate vaccinations, administer the vaccine or refer the patient to a provide who will, and to document the administered vaccines. A strong emphasis on the immunization neighborhood built around collaboration, coordination and communication are the pillars supporting the measures in this area.

AVAC is concerned that potentially removing this measure as a priority would send the wrong signal to providers about the importance of adult immunization and result in reductions in coverage rates among this population. As a nation, we presently lag behind Healthy People 2020 targets for adult immunizations and simply cannot afford to lose ground.

Question: How should ONC define ‘‘widespread’’ in quantifiable terms across these measures? Would this be a simple majority, over 50%, or should the threshold be set higher across these measures to be considered ‘‘widespread’’?

AVAC would encourage ONC to define “widespread” in a manner that is realistic and achievable in the beginning and seek to modify the term as interoperability takes hold across a wide arrange of providers and health care settings. AVAC urges ONC to consider incentives and benchmarks that will gradually encourage the range of meaningful EHR users or other documentation system (like pharmacies) who are immunization providers in the community to input adult immunization records into state and jurisdictional IIS’.

Thank you for this opportunity to offer our perspective on this series of questions being considered by ONC. Please contact the AVAC Coalition Manager at (202) 540-1070 or info@adultvaccinesnow.org if you wish to further discuss our responses or would like to learn more information about AVAC and our work.

Sincerely,

American Association of Occupational Health Nurses
American College of Preventive Medicine
American Pharmacists Association
Asian Pacific Islander American Health Forum
BIO
Gerontological Society of America
GSK
Hepatitis B Foundation
Medicago
Merck
National Association of County and City Health Officials
National Council of Asian Pacific Islander Physicians
Novavax
Pfizer
Sanofi
Takeda
Trust for Americas Health

AVAC Responds to National Committee for Quality Assurance (NCQA) Proposed Modifications to the Pneumococcal Vaccination for Older Adults measure

AVAC wrote to NCQA to express support for NCQA’s proposed modification of the “Pneumococcal Vaccination for Older Adults” measure collected through the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS). AVAC also encouraged NCQA to continue to work with CMS to update, further refine, and streamline pneumococcal vaccination-related quality measures.

Letters to Administration

Quality Measures

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As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the National Committee for Quality Assurance (NCQA) proposed modifications to the Pneumococcal Vaccination for Older Adults measure.

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.

We support NCQA’s proposed modification of the “Pneumococcal Vaccination for Older Adults” measure collected through the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®).

The current question asks: “Have you ever had a pneumonia shot? This shot is usually given only once for twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”

We believe the suggested changes below will help to bring the patient survey question closer in line with current pneumococcal immunization recommendations by Advisory Committee for Immunization Practice (ACIP) for adults age 65 and older. “Have you ever had one or more pneumonia shots? Two shots are usually given in a person’s lifetime and these are different from a flu shot. It is also called the pneumococcal vaccine.”

While the 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 help provide better information in terms of whether or not adults age 65 and older are being properly immunized against pneumonia.

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 NCQA to continue to work with CMS to update, further refine and streamline pneumococcal vaccination-related quality measures.

We are grateful to NCQA for taking this intervening action in light of the significant toll pneumonia takes in terms of lives and health care costs, particularly among our elderly population. We look forward to further action to clarify and refine the collection of quality measure data on pneumococcal immunization coverage. Please contact an AVAC manager at (202) 540-1070 or info@adultvaccinesnow.org if you wish to discuss our comments or adult immunization.

Alliance for Aging Research
American College of Preventive Medicine
Asian and Pacific Islander American Health Forum
Immunization Action Coalition
National Association of City and County Health Officials
Takeda Vaccines
The Gerontological Society of America

AVAC Releases Statement Applauding CMS for Recommending that Part D Plans Offer Covered Vaccines at No or Low-Cost

AVAC applauded CMS for once again recommending that Part D plans offer covered vaccines to all beneficiaries at no or low-cost in the 2017 Medicare Advantage (MA) and Part D Payment Policies and Final Call Letter. No American should be denied access to life-saving vaccines because they lack the ability to pay.

Letters to Administration

Reducing Financial Barriers

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The following is a statement from the Adult Vaccine Access Coalition (AVAC), regarding the adult vaccine provisions of the Centers for Medicare and Medicaid Services 2017 Medicare Advantage (MA) and Part D Payment Policies and Final Call Letter

“The Adult Vaccine Access Coalition (AVAC) applauds the Centers for Medicare and Medicaid Services (CMS) for once again recommending that Part D plans offer covered vaccines to all beneficiaries at no or low-cost. No American should be denied access to life-saving vaccines because they lack the ability to pay.

Adult immunization receives scant attention but has significant health and financial repercussions. Every year, more than 50,000 adults in the United States die from vaccine preventable diseases and thousands more suffer serious health problems that recommended vaccines can prevent—particularly among minority populations for whom immunizations rates are typically far lower than average. Vaccine preventable diseases also cost the United States billions of dollars each year in entirely avoidable healthcare expenditures, lost wages and other indirect economic costs.

As a diverse coalition of health care providers, vaccine manufacturers, pharmacies, and public health, patient, and consumer groups, AVAC is committed to improving Americans’ health by ensuring that recommended vaccines reach more people who need them. We strongly urge all Part D plans to follow CMS’s recommendations and make all covered vaccines available to all beneficiaries free of charge.”

AVAC Urges Congress to Prioritize Funding for Adult Immunization-related Activities at HHS

AVAC sent a letter to members of the House of Representatives and the Senate asking them to prioritize funding for adult immunization-related activities at the Department of Health and Human Services (HHS). Specifically, AVAC requested $650 million for the national immunization program, also known as the 317 program, at the CDC; $82 million in Public Health Service Evaluation Funds for the Office of the National Coordinator for Health IT (ONC); and $6.4 million for the National Vaccine Program Office (NVPO) at HHS.

Letters to Congress

Appropriations/Funding for Immunization

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Dear Senators/Representatives:

As you prepare the Fiscal Year (FY) 2017 Labor, Health and Human Services, Education, and Related Agencies Appropriations bill, we urge you to prioritize funding for adult immunization-related activities at the Department of Health and Human Services (HHS).

Every year, more than 50,000 adults die from vaccine-preventable diseases, and thousands more suffer serious health problems that cause them to miss work and leave them unable to care for those who depend on them. Despite Advisory Committee for Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag far behind the Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Adult Tetanus, Diphtheria, Pertussis (Tdap), shingles, Human Papillomavirus (HPV)). These disparities are even greater when you consider at-risk populations – including seniors, communities of color, limited English proficient persons, and people with chronic illness.

The Adult Vaccine Access Coalition (AVAC) works to raise awareness, improve access, and increase utilization of vaccines among adults. AVAC consists of 45 organizational leaders that include health care providers, vaccine makers, pharmacies, public health organizations, patient and consumer groups working to strengthen and enhance access to and utilization of adult immunizations.

AVAC asks that you consider the benefits of protecting adults against vaccine-preventable disease, the challenges and barriers currently impeding adult immunization, and, the need to catalyze action to strengthen the vaccine infrastructure and delivery systems across the country during the FY17 appropriations process. Specifically, we urge you to prioritize the following immunization related programs as part of your FY17 appropriations request:

Centers for Disease Control and Prevention (CDC) Section 317 Immunization Program. We ask that Congress provide $650 million for the national immunization program, also known as the 317 program, at the CDC. A robust immunization infrastructure is critical to support and protect the population against common preventable conditions as well as potential disease outbreaks or public health emergencies. The Section 317 program acts as the backbone of our nation’s public health infrastructure. This national, state and local network also provides a safety net to uninsured and poor adults, monitors the safety of vaccines, educates providers and performs community outreach, and conducts surveillance, laboratory testing, and epidemiology to respond to disease outbreaks. AVAC is particularly interested in 317 program investments in Immunization Information Systems (IIS) that improve data exchange security standards and enhance interfacing with electronic health records (EHRs). IIS’ can help inform providers and support clinical decision-making in terms of a patient’s immunization status as well as help determine recommended vaccines.
Office of the National Coordinator for Health IT. We ask that Congress support $82 million in Public Health Service Evaluation Funds for the Office of the National Coordinator for Health IT (ONC). Advancements in health IT (HIT) create opportunities for greater access to and utilization of immunizations among adults. Technology has the power to inform providers about recommended vaccines for the adult population. The ONC is engaged in pilot studies aimed at tackling technological and logistical barriers that will foster a provider’s ability to receive and send a comprehensive record of a patient’s immunization status to determine which vaccines are needed. ONC is also leading important work that will enable patients, family members and other caregivers to directly access immunization records through a web-based portal. These pilot studies hold great promise and should be expanded to test other innovative models that will help to improve the exchange of timely and complete immunization record information.
National Vaccine Program Office. We urge Congress to provide level funding of $6.4 million for the National Vaccine Program Office (NVPO) at HHS. These dollars will help ensure robust implementation of the National Adult Immunization Plan (NAIP). This comprehensive plan lays out overarching goals along with a series of tangible objectives aimed at raising adult immunization rates in line with Healthy People 2020 targets. The NAIP also contains specific milestones intended to monitor progress on improving adult immunization.

The future for adult immunization is bright but adequate funding will be essential to achieving success in addressing the current barriers and challenges to improved access and higher coverage rates for this population. We appreciate your consideration of funding for adult immunizations at CDC, ONC, and NVPO. We look forward to working with your office as the FY17 appropriations process moves forward. For further information, please contact the AVAC mangers at 202-540-1070 or info@adultvaccinesnow.org.

Sincerely,

Alliance for Aging Research
American College of Preventive Medicine (ACPM)
Asian & Pacific Islander American Health Forum (APIAHF)
Biotechnology Innovation Organization (BIO)
GSK
Immunization Action Coalition
Infectious Diseases Society of America
March of Dimes
National Association of City and County Health Officials (NACCHO)
National Viral Hepatitis Roundtable (NVHR)
Novavax
Pfizer
Sanofi Pasteur
Takeda
The Gerontological Society of America
Trust for America’s Health

AVAC Responds to CMS 2017 Medicare Advantage and Part D Advance Notice and Draft Call Letter

AVAC shared comments on CMS’s 2017 Medicare Advantage and Part D Advance Notice and Draft Call Letter. AVAC asked CMS to 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.

Letters to Administration

Reducing Financial Barriers

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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 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

AVAC Responds to the Centers for Medicare and Medicaid Services (CMS) Quality Measure Development Plan (MDP)

The Measure Development Plan (MDP) outlined the nine MACRA requirements of the MDP and sets for CMS’ proposed approach to each requirement. AVAC offered comments on each of the following MACRA requirements.

Letters to Administration

Quality Measures

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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