February 9, 2018

Seema Verma
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-5522-P
P.O. Box 8013
Baltimore, MD 21244-8013

RE: Stakeholder Recommendations for Potential Consideration of New Specialty Measure Sets and/or Revisions to the Existing Specialty Measure Sets for the 2019 Program Year of Meritbased Incentive Payment System (MIPS)

Dear Administrator Verma:

AVAC appreciates the opportunity to offer comments in response to the Potential Consideration of New Specialty Measure Sets and/or Revisions to the Existing Specialty Measure Sets for the 2019 Program Year of Merit-based Incentive Payment System (MIPS). As a stakeholder interested in advancing physician payment models that encourage access to essential preventive services such as immunization, we are grateful to CMS for its continued work and stakeholder engagement 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 towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our mission is informed by scientific and empirical evidence in support of the benefits immunizations provide by improving health, protecting lives against debilitating and potentially deadly conditions, and avoiding unnecessary costs to the healthcare system and to society.

AVAC 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 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 for Immunization Practices (ACIP) recommendations, vaccines are underutilized in the adult population and lag behind Healthy People 2020 goals for the most commonly recommended vaccines (influenza, pneumococcal, Tdap, hepatitis B, herpes zoster, human papillomavirus vaccine (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.

AVAC values the opportunity to offer our perspective on the current specialty measure sets as well as potential new MIPS measures being considered for implementation. As the Medicare program transitions from a volume-based physician payment model to a system that rewards value, it is important that proven prevention interventions such as immunizations are represented. Our coalition firmly believes that adult immunization quality measurement is central to ensuring continued focus on this core prevention intervention. 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 bring increased value without adding burden on providers.

AVAC believes that adult immunization quality measurement meets the three core strategies underlying the movement toward a truly patient-centered health care delivery system by: 1) Improving the way clinicians are paid to incentivize quality and value of care over simply quantity of services; 2) improving the way care is delivered by providing clinical practice support, data and feedback reports to guide improvement and better decision-making and; 3) making data more available in real-time at the point of contact and enabling the use of certified Electronic Health Record (EHR) technology and other data sources to support care delivery.

CY2018 MIPS Specialty Measure Sets
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. 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 2018 Quality Payment Program added immunization quality measures to several specialty measure sets. AVAC was encouraged that the following specialty sets included the following immunization process quality measures in the final rule:

✓ Allergy/Immunology. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults
✓ Family Medicine. NQF# 0041 Preventive Care and Screening: Influenza Immunization, NQF# 0043 Pneumonia Vaccination Status for Older Adults and NQF # 1407 Immunizations for Adolescents
✓ Infectious Disease. NQF# 0041 Preventive Care and Screening: Influenza Immunization, NQF# 0043 Pneumonia Vaccination Status for Older Adults and NQF # 1407 Immunizations for Adolescents
✓ Nephrology. NQF# 0041 Preventive Care and Screening: Influenza Immunization, NQF# 0043 Pneumonia Vaccination Status for Older Adults
✓ Obstetrics/Gynecology. NQF# 0041 Preventive Care and Screening: Influenza Immunization.
✓ Otolaryngology. NQF# 0041 Preventive Care and Screening: Influenza Immunization, NQF# 0043 Pneumonia Vaccination Status for Older Adults
✓ Pediatrics. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF #0038 Childhood Immunization Status and NQF # 1407 Immunizations for Adolescents
✓ Preventive Medicine. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults
✓ Rheumatology. NQF# 0041 Preventive Care and Screening: Influenza Immunization, NQF# 0043 Pneumonia Vaccination Status for Older Adults

AVAC was, however, disappointed that the final rule did not include quality measures aimed at patients at greater risk of serious complications from vaccine preventable illness. The ACIP includes age-based, as well as condition-specific recommendations for adult vaccination. For pregnant women, ACIP recommends a Tdap vaccination. We are pleased that efforts to develop a composite Tdap/influenza measure for pregnant women has completed testing and is now under review by the National Committee for Quality Assurance (NCQA). AVAC looks forward to further dialogue your agency on this topic as it moves forward.

In addition, patients living with chronic conditions such as heart disease and diabetes are at a significantly higher risk of complications and death from influenza and pneumonia. The CDC has reported that in 2013 only 21.2% of adults in this group had received a pneumococcal vaccination, and this number has been essentially unchanged for at least a decade. Individuals with diabetes are at increased risk for hepatitis B infection. As such, the ACIP recommends hepatitis B vaccination for all patients with diabetes age 606 and under as well as other at-risk patients, such as those living with HIV/AIDS and chronic kidney disease.

We strongly encourage CMS to add the following immunization quality measures into these specialty measure sets:

➢ Internal Medicine. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults.
➢ Endocrinology. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults.
➢ Cardiology. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults.
➢ General Surgery. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults.
➢ Oncology. NQF# 0041 Preventive Care and Screening: Influenza Immunization and NQF# 0043 Pneumonia Vaccination Status for Older Adults.

MIPS Measures under Consideration
AVAC is pleased to have the opportunity to offer comments on potential measures to be included in specialty measure sets. In terms of adult immunization, the Measures under Consideration (MUC) includes the following measure for herpes zoster (shingles) immunization, “The percentage of patients 60 years of age and older who have a Varicella Zoster (shingles) vaccination.” The absence of zoster vaccination measures was identified by the National Quality Forum as a significant gap in performance measurement and the development of a measure had been identified as a priority.

AVAC urges CMS to consider incorporating this important measure under the following specialty sets: Cardiology, Family Medicine, Infectious Disease, Internal Medicine, Nephrology, Oncology, Preventive Medicine.

Presently, a Herpes Zoster (Shingles) vaccination process measure is only being utilized in the home health value-based payment program – Herpes Zoster (Shingles) Vaccination: Has the Patient Ever Received the Shingles Vaccination? AVAC supports broader adoption of a herpes zoster measure across specialty sets to reduce the number of missed immunization opportunities for this debilitating condition.

According to the CDC, 27.9 percent of adults age 60 and older reported receiving the herpes zoster vaccine. 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. We hope that CMS will explore including a herpes zoster measure in other value-based purchasing and quality reporting programs in the future, particularly since there new ACIP recommendations.

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 Quality Payment Program and in keeping current clinical guidelines in the coming years.

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 Immunization Registry Association (AIRA)
Asian Pacific Islander American Health Forum
BIO
Dynavax
Every Child By Two (ECBT)
Families Fighting Flu
GSK
Hepatitis B Foundation
Hep B United
Infectious Diseases Society of America (IDSA)
Immunization Action Coalition
Immunization Coalition of Washington DC
National Association of County and City Health Officials (NACCHO)
National Foundation for Infectious Diseases (NFID)
Novavax
Sanofi
Sequirus
Takeda Vaccines, Inc.
The Gerontological Society of America
Trust for America’s Health