September 11, 2017

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1678-P
P.O. Box 8013
Baltimore, MD 21244-1850

Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs

To Whom It May Concern:

As members of the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Medicare Program Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs proposed rule.

AVAC includes more than fifty organizational leaders in health and public health who are committed to addressing barriers to adult immunization and to raising awareness of and engaging in advocacy on the importance of adult immunization. Our mission is informed by scientific and empirical evidence that shows immunization improves health, protect lives against a variety of debilitating and potentially deadly conditions, and save 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 stakeholders to have a voice in the effort to improve access to and utilization of adult immunizations. 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 problems. Despite Advisory Committee on Immunization Practices (ACIP) recommendations, vaccines have been consistently underutilized in the adult population and lag behind the Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Tdap (tetanus, diphtheria, pertussis), hepatitis B, herpes zoster, HPV). Disparities are even greater for at-risk populations, including seniors and people with chronic illnesses.

We note that the proposed rule includes changes intended to make Outpatient Prospective Payment System (OPPS) payments for all services more consistent with those of a prospective payment system and less like those of a per-service fee schedule. Within that overarching goal, we appreciate CMS’ acknowledgment that preventive services are different from other Medicare Part B drugs, and as such, are excluded from the majority of the proposed changes to packaging and other policies. AVAC supports the proposal to continue to pay separately for Medicare Part B vaccine administration services.

It is important to understand the unique and relatively complex nature of immunization services for clinicians. Many providers struggle with storage, inventory, and payment hurdles for vaccines. Managing all of these aspects under a capitated arrangement can actually result in declines in vaccine utilization. The unique cost and management challenges associated with vaccines in the provider office should be considered and not serve a disincentive for providers, particularly those serving low-income/minority populations. Standardizing the offering of vaccines has been shown to reduce differences in vaccination rates. Adequate provider payment rates support an important foundation of prevention through immunization.

Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgical Center Quality Reporting (ASCQR) Programs

The proposed rule includes Hospital OQR program measures sets previously adopted for CY 2020 payment determination as well as a table summarizing proposed and previously adopted measures for CY 2020 and beyond. Similarly, the proposed rule also includes measure sets previously finalized for the ASCQR for CY 2020 payment determination as well as measure sets previously finalized and proposed for CY 2021 and subsequent years’ payment determination. AVAC appreciates that both the Hospital OQR and ASCQR programs maintain Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431) among the core measure sets. Leading medical and health professional associations support influenza vaccination policies for healthcare professionals to help protect patients. AVAC strongly supports maintaining this measure in the Hospital OQR and ASCQR programs in the final rule.

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 only 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 outpatient and ambulatory surgical healthcare settings and should remain a priority within these programs.

The Medicare Program Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs present an important opportunity to promote higher quality and more efficient health care for Medicare beneficiaries. AVAC believes the Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgical Center Quality Reporting (ASCQR) should also include a focused, concerted effort to improve access to and utilization of adult immunizations as a means of improving the overall health of Medicare beneficiaries. Last year, AVAC released a White Paper outlining the value and imperative of quality measures for adult vaccines. The paper 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.

AVAC also encourages CMS to consider including influenza and pneumococcal immunization measures in the OQR and ASCQR programs and eventually incorporate measures that address all ACIP-recommended vaccines for adults. The health and economic burden of pneumococcal disease, particularly among elderly and high-risk adult populations, is significant. Yet,
Yet, 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.

Future Measure Topics

AVAC appreciates the opportunity to respond to the request for comment on possible measure topics for future consideration in the Hospital OQR program. As the proposed rule notes, CMS programs are moving toward greater use of outcome measures and away from clinical process measures. Prioritizing quality measures around immunization in the Hospital OQR Program would help close existing measure gaps, improve upon immunization rates and health outcomes for the millions of Medicare beneficiaries seeking care in the outpatient hospital setting.

The proposed rule also notes intent to develop a quality measure set for the ASCQR Program that focuses on the following NQS and CMS Quality Strategy measure domains: Make care safer by reducing harm caused in the delivery of care; strengthen person and family engagement as partners in their care; promote effective communication and coordination of care; promote effective prevention and
treatment of chronic disease; work with communities to promote best practices of healthy living; and make care affordable.

AVAC strongly urges CMS to consider including a core set of 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 CMS’ future measure selection and development process for the Hospital OQR and ASCQR Programs. Screening should be done by primary care, as well as specialty providers to ensure that everyone is counseled and has the opportunity to receive the appropriate 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.

AVAC 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 toward improving upon adult immunization quality measures in both the Hospital OQR and ASCQR. AVAC shares your goal of building, strengthening and advancing a new generation of 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 the burden on providers while ensuring the integrity and societal value of quality measurement.

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 for Medicare beneficiaries through outpatient and ambulatory surgical settings is an important step to improving health and reducing the burden of vaccine-preventable illness among this population.

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

Alliance for Aging Research
Dynavax Technologies Corporation
Families Fighting Flu
Immunization Action Coalition
The Gerontological Society of America