June 26, 2017

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1679-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 2018, 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 (QRP).

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 priorities and objectives are driven by a consensus process, towards the goal of 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. 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.

SNF QRP Quality Measures Under Consideration for Future.
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. The proposed rule requests comment on “the importance, relevance, appropriateness and applicability” of the quality measures described in Table 19 for inclusion in the SNF QRP in future years.

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 each year. According to a study in the Journal of Primary Prevention, this vaccine-preventable disease costs the United States about $8.3 billion annually to treat 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.

Preventing transmission of influenza and other infectious agents within long-term care settings requires a multi-faceted and sustained 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 the annual influenza vaccine. AVAC supports the proposal to include the Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine in the SNF QRP and urges its inclusion as quickly as practical.

Proposed Standardized Resident Assessment Data Reporting for the SNF QRP.
The proposed rule discusses CMS efforts to identify standardized patient assessment data that could be incorporated into assessment instruments across post-acute care settings. Consistent application of adult immunization quality measures across health care settings is an AVAC priority. Greater consistency will facilitate data exchange across health care providers as well as improve care coordination and ultimately patient outcomes. In that vein, preventing transmission of influenza virus within healthcare settings requires a multi-faceted, cross-cutting approach. Inclusion of the Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine measure in the SNF QRP would align with ongoing efforts to collect and report this measure in the Long-term Care Hospital Quality Reporting Program (LTCHQRP).

Other Measures to Consider for Future SNF QRP Inclusion.
AVAC believes the SNF QRP should include a focused, concerted approach to adult immunizations as a means of improving the overall health of patients living in skilled nursing facilities. We encourage CMS to consider prioritizing a broader set of ACIP recommended immunization measures for consideration for future inclusion in the SNF QRP. In particular, the current lack of pneumococcal quality measures in the SNF QRP is a missed opportunity to improve health and reduce unnecessary federal expenditures on treatment and hospitalizations as a result of this vaccine preventable disease.

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 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).

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 proposed 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.


Alliance for Aging Research
Asian & Pacific Islander American Health Forum
Immunization Action Coalition
National Association of County and City Health Officials
National Foundation for Infectious Diseases
Takeda Vaccines, Inc.
The Gerontological Society of America