June 26, 2018

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1690-P
P.O. Box 8010
Baltimore, MD 21244-1810

RE: CMS-1690-P Medicare Program; FY 2019 Inpatient Psychiatric Facilities Prospective Payment System and Quality Reporting Updates for Fiscal Year Beginning October 1, 2018 (FY 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 Hospital Inpatient Psychiatric Facilities 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.

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.1 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.2 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.

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.4 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.5

Preventing transmission of influenza and other infectious agents within inpatient psychiatric 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 the annual influenza vaccine.

The proposed rule would maintain Influenza Immunization IMM-2 (NQF #1659) for the FY2020 payment year, we are deeply concerned that the proposed rule seeks to remove Influenza Vaccination Coverage Among Healthcare Personnel (NQF#0431) from the Inpatient Psychiatric Facilities (IPF) Quality Reporting Program prescribed in the rule. AVAC strongly urges CMS to maintain both measures in the FY 2020 payment reporting year for the reasons outlined in this letter.

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program.
The proposed rule would make several changes to the IPFQR Program, including removal of the Influenza Vaccination Coverage Among Healthcare Personnel (NQF#0431) measure on the basis that the costs associated with this measure outweigh the benefit of its continued use in the program (Factor 8).

The proposed rule indicates that CMS originally adopted the Influenza Vaccination Coverage Among Healthcare Personnel measure (NQF #0431) because “we recognize that influenza immunization is an important public health issue, especially for vulnerable patients who may have limited access to the healthcare system, such as patients in IPFs.” Indeed, persons with mental illness often have lower rates of influenza vaccination as compared to the general population. Many of these patients may also suffer comorbid conditions that make them even more susceptible to the adverse health effects of vaccine-preventable conditions such as influenza.

The Influenza Vaccination Coverage Among Healthcare Personnel measure (NQF #0431) was adopted in the FY 2015 IPF PPS final rule, “due to public health concerns regarding influenza virus infection among the IPF population” and the measure addressed this concern “by assessing influenza vaccination in the IPF among healthcare personnel (HCP), who can serve as vectors for influenza transmission.” A recent commentary, Influenza in long-term care facilities notes, “a study of health care workers (HCW)s in an acute hospital during a mild epidemic season, found that 23% had serological evidence of new influenza infection during the season, implying a potential transmission risk to patients as between 28% and 59% of infected workers had subclinical infections and continued to work.”

The proposal to remove this measure is inconsistent with CMS’ own position and arguments with respect to this same measure in the inpatient hospital quality reporting program. The Hospital Inpatient Prospective Payment System proposed rule (CMS-1694-P) states with respect to the Influenza Vaccination Coverage Among Healthcare Personnel (HCP) measure (NQF #0431), it “promotes improved health outcomes among beneficiaries because: (1) health care personnel that have received the influenza vaccination are less likely to transmit influenza to patients under their care; and (2) vaccination of health care personnel reduces the probability that hospitals may experience staffing shortages as a result of illness that would impact ability to provide adequate patient care. Thus, we believe the costs associated with reporting this chart-abstracted measure outweighs the associated benefits of keeping it in the Hospital IQR Program.”

AVAC strongly believes removal of this 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.

We strongly urge CMS to maintain the Influenza Vaccination Coverage Among Healthcare Personnel (NQF#0431) and support the proposal to maintain the Chart-Abstracted Clinical Process of Care Measure Influenza Immunization IMM-2 (NQF #1659) as part of the program for FY 2020 payment determination and subsequent years as well. 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 span7. 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. Adult coverage lags behind Healthy People 2020 targets for most commonly recommended vaccines: influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, and HPV.

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 continues to work with 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 IPF QR Program 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. Lastly, AVAC strongly supports the future adoption of adult immunization measures to the IPF QRP in this rulemaking. 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. An adult composite measure 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). 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 Center11 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 continued lack of pneumococcal quality measures in Medicare inpatient 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. 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 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 inclusion of the Pneumococcal Vaccination for Older Adults in the IPF QRP 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
National Association of County and City Health Officials
National Hispanic Medical Association
Novavax
Pfizer
Sanofi
Seqirus
Trust for America’s Health