September 25, 2017

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1672-P
P.O. Box 8016
Baltimore, MD 21244-8016

RE: Medicare and Medicaid Programs: CY 2018 Home Health Prospective Payment System Rate Update and Proposed CY2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements

To Whom It May Concern:

AVAC appreciates the opportunity to offer comments in response to the CY 2018 Home Health Prospective Payment System Rate Update and Proposed CY2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. As a stakeholder coalition interested in advancing payment models that encourage access to immunization, we are grateful to the Centers for Medicare and Medicaid Services (CMS) for its work in this area.

AVAC includes more than fifty organizational leaders in health and public health who are committed to addressing barriers to adult immunization. AVAC works toward regulatory and legislative solutions that will strengthen and enhance access to adult immunization across the healthcare system. Our mission is informed by 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. A top priority for AVAC is to achieve increased adult immunization rates through federal benchmarks and performance measures that encourage utilization 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 problems1. Despite Advisory Committee for Immunization Practices (ACIP) recommendations, vaccines are underutilized in the adult population and lag behind the Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Tdap, hepatitis B, herpes zoster, and human papillomavirus (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.

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

The Home Health Value-Based Purchasing Model (HHVBP) presents an important opportunity to promote higher quality and more efficient healthcare for Medicare beneficiaries. AVAC values the opportunity to offer our comments on aspects of the proposed rule relevant to the provision of immunizations. Our coalition firmly believes that adult immunization quality measurement is central to ensuring continued focus on this core prevention intervention. We look forward to working with you to improve upon existing adult immunization quality measures and to advance new measures for current vaccines and future vaccines in the pipeline. AVAC shares your goal of building, strengthening and advancing a new generation of process and outcome measures, as outlined in the CMS Quality Strategy. We are also committed to ensuring this new generation of adult immunization measures strikes the right balance in terms of not adding a burden on providers while enhancing the integrity and societal value of quality measurement.

AVAC believes the home health proposed rule should include a focused, concerted effort to improve access and utilization of adult immunizations as a means of improving the overall health of Medicare beneficiaries receiving home health services. Last summer, AVAC released a White Paper outlining the value and imperative of quality measures for adult vaccines.4 The report highlights the role of vaccine quality measures in preventing illness and death, reducing caregiving demands, avoiding unnecessary healthcare spending, and setting the foundation for healthy aging.

p. 35335 Measure Set for the HHVBP Model Beginning in Performance Year 3

The proposed rule maintains several immunization measures in the Home Health Value-Based Purchasing (HHVBP) program and well as the Home Health Quality Reporting program. These process measures are important tools to incentivize and encourage adult immunization in the home health setting. Specifically, AVAC commends CMS for maintaining the following measures (see Table 43) among the Population/Community Health measures for the HHVBP Performance Year 3 and urges CMS to maintain them in the final rule.

➢ Influenza Immunization Received for Current Flu Season (NQF#0522)
➢ Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431) and
➢ Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination?

The proposed rule also maintains Pneumococcal Polysaccharide Vaccine Ever Received (NQF#0525), however, it is worth noting that this measure no longer reflects current recommendations of the Advisory Committee on Immunization Practices (ACIP). AVAC strongly encourages CMS to replace this outdated measure in the final rule. Other CMS quality programs have implemented Pneumonia Vaccination Status for Older Adults (NQF#0043), as it better reflects the current Advisory Committee for Immunization Practice (ACIP) recommendation for PCV13 and PPSV23 vaccination in adults age 65 and older as well as at-risk adults 19-64 years old. The health and economic burden of pneumococcal disease, particularly among elderly and high-risk adult populations, is significant.

According to the Centers for Disease Control and Prevention (CDC), an estimated 900,000 Americans get pneumococcal pneumonia each year, resulting in as many as 400,000 hospitalizations and more than 53,000 deaths. It is estimated that among adults age 65 and older, the annual cost of pneumococcal disease is over $3 billion dollars. Despite the fact that most pneumococcal pneumonia deaths each year are adults, pneumococcal vaccination rates remain inadequate, with only 63 percent of adults over the age of 64 and 22 percent of high risk adults being vaccinated.

By contrast, AVAC appreciates that the HHVBP maintains Influenza Immunization Received for Current Flu Season (NQF#0522) along with Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431). Protecting frail elderly, disabled and chronically ill Medicare beneficiaries against influenza is extremely important. A recent CDC study of flu-associated deaths prevented over a nine-year period from 2005-2006 through 2013-2014 found that nearly 89 percent were in people 65 years of age and older.

Leading medical and health professional associations support influenza vaccination policies for healthcare professionals to help protect patients. The Advisory Committee on Immunization Practices (ACIP) recommends that all healthcare personnel (HCP) be vaccinated annually against influenza. Vaccination of HCP has been associated with reduced rates of work absenteeism and with fewer deaths among nursing home patients and elderly hospitalized patients. Although annual vaccination is recommended for all HCP and is a high priority for reducing morbidity associated with influenza in healthcare settings, national survey data have demonstrated that vaccination coverage levels are approximately 70%, falling short of recommendations under Health People 2020 to increase the number of HCPs receiving an annual influenza vaccination to the target rate of 90%. Healthcare personnel are the first line of defense when it comes to preventing illness and preserving health. Quality measurement reflecting this priority is essential to promoting and advancing prevention in the home health settings.

Additionally, we greatly appreciate that the HHVBP model includes Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination?, as the HHVBP is the only value-based payment program within CMS to recognize the value and importance of a herpes zoster (shingles) vaccination measure. AVAC encourages other CMS programs to follow the lead of HHVBP and include a quality measure assessing whether or not a Medicare beneficiary has received a herpes zoster vaccination.

According to the CDC, 27.9 percent of adults age 60 and older reported receiving the herpes zoster vaccine.10 The health and economic burden associated with shingles and its complications are significant for patients as well as the health care system. In 2007, the Agency for Healthcare Research and Quality (AHRQ) estimated the average cost of shingles and its complications to be $566 million a year while another study estimated the overall cost could be as high as $1.7 billion a year.

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

P. 35345 Measures Currently Adopted for the Home Health Quality Reporting Program (HHQRP)
The Home Health Quality Reporting Program (HHQRP) also includes immunization measures among the 23 quality measures presented in Table 47. The measures are:

➢ Influenza Immunization Received for Current Flu Season (NQF#0522)
➢ Pneumococcal Polysaccharide Vaccine Ever Received (NQF#0525)

While we support maintaining the influenza measure (NQF#0522), we would again urge CMS to replace the pneumococcal measure (NQF#0525) with Pneumonia Vaccination Status for Older Adults (NQF#0043) in the final rule. Together, these measures would represent an important baseline for access to influenza and pneumococcal vaccination services.

Lastly, the FY17 proposed rule included under the Table 33, HHQRP measures for future consideration, the Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay). The proposed measure would fall under the NQS Patient and Caregiver Centered Care category. Given the importance of the annual flu vaccine, we believe this measure presents an important opportunity to help improve overall immunization rates.

AVAC also urges CMS to consider adult immunization quality measures that reflect the recommendations of the Advisory Committee on Immunization Practices (ACIP) adult immunization quality measures, as well as measures that reflect provider assessment of a patient’s immunization status, as part of HHQRP future measure selection and development. Assessment should be done by all health care providers to ensure that all beneficiaries are counseled and have the opportunity to receive the recommended immunizations, based on their age and health status. Published literature indicates that integrating immunization screening and additional providers offering these critical preventive services will result in greater opportunities for immunization. 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. Together, these efforts help to reduce d immunization opportunities among home health patients and result in improved health and reduced disease burden among this frail and vulnerable population.

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 HHVBP and HHQRP.

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

Sincerely,
Alliance for Aging Research
American College of Preventive Medicine
Asian & Pacific Islander American Health Forum (APIAHF)
Every Child by Two
GSK
Immunization Action Coalition
Immunization Coalition of Washington, DC
National Association of County and City Health Officials (NACCHO)
Novavax