To Whom It May Concern:

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter. Specifically:

• AVAC encourages CMS to continue to work with NCQA, PQA and other relevant quality measure stakeholders to update, refine and streamline pneumococcal vaccination-related quality
• AVAC strongly encourages CMS to restore language in the final 2018 call letter encouraging Part D sponsors to consider offering $0 or low cost sharing for vaccines

AVAC consists of over 50 organizational leaders in health and public health that are committed to addressing 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 and protecting lives against a variety of debilitating and potentially deadly conditions, 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.

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 lags behind Healthy People 2020 targets for most commonly recommended vaccines: influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, and HPV. Millions more adults suffer from vaccine-preventable diseases, causing them to miss work and leaving some unable to care for those who depend on them.

One of our key coalition priorities is to advocate for measures that will close immunization coverage gaps for vulnerable populations and improve adult immunization rates overall. Research provides a sense of the immense cost burden attributable to vaccine-preventable disease. A study published in The Journal of Primary Prevention found the estimated annual cost of just four major vaccine-preventable diseases among US adults 65 years and older was more than $15 billion in 2013.1 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 when deemed medically necessary to prevent illness. 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 is a barrier to access that hinders public health and provider efforts to improve immunization rates among elderly and disabled populations.

It is important to note that immunization meets the three aims of the CMS Quality Strategy: Better Care, Smarter Spending, and Healthier People. As such, CMS should prioritize and encourage improved access to and utilization of adult immunization services for beneficiaries in Medicare Advantage and Prescription Drug Plans (PDP). As such, AVAC wishes to offer comments on the following sections of the 2018 draft call letter with the hope that CMS will incorporate our recommendations in the final letter

Pneumococcal Vaccination Status for Older Adults (p. 97)

The draft call letter discusses the National Committee for Quality Assurance (NCQA) change in the wording of a measure collected by the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, the “Pneumococcal Vaccination Status for Older Adults”. 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 immunocompetent adults 65 years of age and older receive both PCV13 and PPSV23. We appreciate that CMS is considering alternate non-survey based methods to assess pneumococcal vaccination status and adherence, including claims, case management systems, medical records, registries and electronic health records and we would encourage CMS to utilize all available sources (e.g., SNOMED-CT) to provide a comprehensive assessment of pneumococcal coverage rates among this population.

In 2015, the Health and Well-Being Committee for the National Quality Forum (NQF) proposed standard specifications for pneumococcal measures in order to better align measures across healthcare settings and to bring measures in accordance with ACIP recommendations.2 AVAC encourages CMS to continue to work with relevant quality measure stakeholders to update, refine and streamline pneumococcal vaccination-related quality measures.

Vaccine tier/ $0 cost sharing (p. 144)

AVAC noted with great disappointment that the 2018 draft call letter did not include language regarding the availability of a special vaccine tier. Last year, the 2017 call letter stated, “We encourage Part D sponsors to consider offering $0 or low cost-sharing for vaccines to promote this important benefit.”3 Similar language has been included in the CMS call letter since 2012. Despite ACIP’s evidence-based clinical guidelines on the appropriate ages, underlying chronic diseases and recommended vaccines for adult immunization, rates still remain extremely low. According to the 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.4 Yet, this year’s letter makes only a vague reference to the vaccine tier in a footnote.

There is a growing body of scientific evidence that indicates financial barriers to Part D vaccines impede beneficiary access to immunization services. A 2015 report by the Alliance for Aging Research 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.5 Similarly, 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 2015.6 In 2015, only 81 of 1,945 MA plans offer a special vaccine tier to beneficiaries.

AVAC strongly encourages CMS to restore language in the final 2018 call letter encouraging Part D sponsors to consider offering $0 or low cost sharing for vaccines. Furthermore, AVAC urges CMS to consider offering incentives, such as allowing Part D plan sponsors to 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 discourage immunization among elderly, disabled and chronically ill populations who account for a disproportionate percentage of the morbidity and mortality from vaccine preventable conditions. Removing this financial barrier would have a significant impact on improving beneficiary access to and utilization of vaccines. Addressing this barrier will be even more important to improving uptake as new vaccines for a growing variety of infectious and devastating conditions are expected to enter the market.

Thank you for the opportunity to offer our perspective on the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter. We hope CMS will restore 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 important preventive health services. Please contact an AVAC manager at (202) 540-1070 or info@adultvaccinesnow.org if you wish to discuss our comments or adult immunization access and coverage issues.

Sincerely,

Alliance for Aging Research
American College of Preventive Medicine
American Immunization Registry Association (AIRA)
Asian & Pacific Islander American Health Forum (APIAHF)
Association of Immunization Managers (AIM)
Biotechnology Innovation Organization (BIO)
Gerontological Society of America
GSK
Hep B United
Hepatitis B Foundation
Immunization Action Coalition (IAC)
Medicago
Merck
National Association of Chain Drug Stores (NACDS)
National Association of City and County Health Officials (NACCHO)
National Foundation for Infectious Diseases (NFID)
National Hispanic Medical Association
Pfizer
Pharmacy Quality Alliance
Sanofi
Trust for America’s Health (TFAH)