June 26,2018

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1688-P
P.O. Box 8016
Baltimore, MD 21244-8016

RE: CMS–1694–P Medicare Program: Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019

To Whom It May Concern:

As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Medicare Program Inpatient Rehabilitation Facility Prospective Payment proposed rule for Fiscal Year 2019.

AVAC consists of over 50 organizational leaders in health and public health that are committed to addressing 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 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 improved tracking and reporting of immunization status that will result in increased adult immunization rates. Immunization quality measures are a crucial tool for health care quality improvement and have demonstrated effectiveness in increasing immunization rates.

Opportunities to assess the immunization status of Medicare beneficiaries for should be done by the range of clinicians who care for them, including primary care and specialty providers. Taking advantage of each and every patient encounter to ensure that counseling and education on vaccines, based on their age and health status, and a strong provider recommendation have been found to improve the likelihood of a patient being immunized. Published literature indicates that integrating immunization assessment and additional providers offering these critical preventive services will result in greater opportunities for immunization.1 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.

The proposed rule would maintain the Influenza Vaccination Coverage Among Healthcare Personnel (NQF#0431) for the FY2020 payment year, but we are deeply concerned that the proposed rule seeks to remove the Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) from the Inpatient Rehabilitation Facility Quality Reporting Program for fiscal year 2021. AVAC strongly urges CMS to maintain both for the reasons outlined in this letter.

IRF Quality Reporting Program (IRF QRP).

The proposed rule would remove two measures from the IRF QR Program, including the Influenza Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) measure on the basis that “measure performance among IRFs is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made.” (Factor 1) The measure was adopted in the FY 2014 IRF PPS final rule because many patients receiving care in the IRF setting are 65 years and older and considered to be the target population for the influenza vaccination.

Specifically, the CMS analysis revealed that for the 2015-2016 and the 2016-2017 influenza seasons, nearly every IRF patient was assessed and more than 75 percent of IRFs (n = 836) were vaccinating IRF patients who had not already received a flu vaccination. Additionally, over the last two influenza seasons, the number of IRFs who achieved a perfect score (100 percent) on this measure has grown substantially, increasing by approximately 50 percent from 146 IRFs (12.9 percent) in the 2015-2016 influenza season to 210 IRFs (18.8 percent) in the 2016-2017 influenza season. The mean performance score for this measure was between 91.04 and 93.88 percent over the last two influenza seasons. The proposed rule states, “proximity of these mean rates to the maximum score of 100 percent suggests a potential ceiling effect and a lack of variation that restricts distinction between facilities. Given that performance among IRFs has remained so high and that no meaningful distinction in performance can be made across the majority of IRFs, we are proposing the removal of this measure.”

AVAC strongly disagrees with this contention. Removal of the Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) of from the IRF QR Program will send the impression to rehabilitation hospitals that preventive health care services such as immunization are no longer a priority, despite the serious economic and health consequences of influenza outbreaks in the inpatient setting. The fact that the analysis of the measure for the last two influenza seasons indicates that nearly every IRF assessed and vaccinated patients is a clear indicator of the success of the measure. Sustained widespread assessment and documentation of influenza vaccination and the adoption of a composite metric reflecting the array of vaccines recommended by the ACIP should remain an utmost priority for patients in IRF settings since individuals residing in long-term care facilities “present a population very susceptible to the acquisition and spread of infectious diseases and for whom the consequences may be serious.”

AVAC strongly believes removal of the measure from the IPFQR program would create greater inconsistency across inpatient quality reporting programs, add to provider reporting confusion and ultimately leave an extremely vulnerable population of Medicare beneficiaries more susceptible to vaccine-preventable illness. These measures play a critical role in the CMS Quality Strategy as well as the National Quality Strategy in terms of influenza immunization efforts.

Influenza Quality Measures.
In the draft Strategic Plan FY 2018 –2022, the Department of Health and Human Services encourages the use of age-appropriate vaccines to minimize the burden of vaccine-preventable diseases across the life span.4 Unfortunately, access to vaccines is not equal across a person’s lifespan. 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.

Preventing transmission of influenza and other infectious agents within inpatient hospital settings requires a multi-faceted approach since the spread of influenza can occur among patients, Health Care Professionals (HCP), and visitors. Quality measurement programs through Medicare play a critical role in promoting improved quality and encouraging adherence to and consistent utilization of the annual influenza vaccine.

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 an average of 36,000 deaths in the United States alone. A Centers for Disease Control and Prevention (CDC) review of deaths associated with seasonal influenza between 1976 and 2007 found that 90 percent were among adults age 65 and older. According to a study in the Journal of Primary Prevention, this costs the United States about $8.3 billion or 54 percent of the total annual cost to treat vaccine-preventable diseases among US adults 65 and over. Influenza immunization measures help increase access and utilization of this important vaccine by patients and health care providers alike.

In addition, data transparency of reported measures is an important tool for patients and families seeking to evaluate post-acute care settings and an essential component in the identification and management of influenza outbreaks. Tracking vaccine status among health care workers has the ability to increase vaccination rates and reduce absenteeism among healthcare personnel. We support public reporting IRF QRP data on a CMS website, such as IRF Compare and support maintaining the two above measures in this campaign. 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.

Social Risk Factors. 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. The proposed rule indicates that CMS is currently reviewing reports by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the National Academies of Sciences, Engineering and Medicine on accounting for social risk factors in the Hospital IQR Program. We support the idea of future stratification of IFR QRP data by race, ethnicity, geographic area, 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. AVAC believes the IRF QRP should include a focused, concerted approach to adult immunizations as a means of improving the overall health of patients in post-acute care facilities. The HHS National Vaccine Program Office (NVPO) and the Centers for Disease Control and Prevention (CDC) in collaboration with the National Adult Immunization and Influenza Summit Quality Working group have been instrumental in spearheading the development and testing of a new composite measure for adult immunization, along with measures for maternal immunization and end-stage renal disease patients. AVAC strongly supports an adult immunization measures that incorporate ACIP-recommended vaccines and we look forward to working with CMS to support their widespread adoption. AVAC strongly supports the future adoption of an adult immunization composite measure that would provide a sound, reliable and comprehensive means to assesses the receipt of routine adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP). We encourage CMS to consider future adoption in the IRF QRP of adult immunization measures that reflects ACIP recommended vaccines. We value your request for comment on potential new quality measures under consideration for future inclusion in the IRF Quality Reporting Program. AVAC appreciates the work of The National Committee for Quality Assurance (NCQA), Pharmacy Quality Alliance (PQA, Inc.), and others to develop and test reliable measurement tools that will streamline the patchwork of existing adult immunization measures, reduce the reporting burden on providers, and provide meaningful data to the Medicare program on access to this important preventive service.

In the Value and Imperative of Quality Measures for Adult Vaccines, renowned vaccine experts explain how quality measures that capture and create incentives for appropriate adult vaccinations can prevent illness and death, reduce caregiving demands, save unnecessary healthcare spending, and set the foundation for healthy aging. There is evidence that a composite measure of the adult immunization schedule, such as those demonstrated by the Northwest Tribal Epidemiology Center12 and by the National Nursing Home Quality Care Collaborative, can improve patient health outcomes. Such a measure would put vaccination coverage rates into a larger context and encourage a more systematic approach for all vaccines.

In the meantime, the current lack of pneumococcal quality measures in Medicare inpatient hospital quality reporting programs is a missed opportunity to improve health and reduce unnecessary federal expenditures on treatment and hospitalizations as a result of this vaccine-preventable disease. 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 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 both 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 NCQA Pneumococcal Vaccination Coverage for Older Adults measure pneumococcal immunization measurement back into the IRF quality reporting program and across the other inpatient hospital quality reporting programs.

We appreciate this opportunity to share our perspective on this proposed rule. 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,

Asian & Pacific Islander American Health Forum
Biotechnology Innovation Organization (BIO)
Every Child By Two
Gerontological Society of America
GSK
Immunization Action Coalition
Medicago
National Association of County and City Health Officials
National Hispanic Medical Association
Novavax
Pfizer
Sanofi
Seqirus
Trust for America’s Health