BIO Comments on CMS Proposed Methodology for 2013 Star Ratings for Medicare Advantage and Prescription Drug Plans

Re: Request for Comments Regarding Enhancements to the Part C and Part D Plan Ratings

The Biotechnology Industry Organization (BIO) appreciates this opportunity to comment on the Centers for Medicare and Medicaid Services’ (CMS) proposed methodology for 2013 star ratings for Medicare Advantage (MA) and Prescription Drug Plans. BIO represents more than 1,100 biotechnology companies, academic institutions, state biotechnology centers and related organizations across the United States and in more than 30 other nations. BIO members are involved in the research and development of innovative healthcare, agricultural, industrial and environmental biotechnology products. BIO membership includes both current and future vaccine developers and manufacturers who have worked closely with the public health community to support policies that help ensure access to vaccines for all individuals.

BIO supports the development and use of appropriate, evidence-based quality measures throughout the healthcare system. Quality measures for adult immunizations help ensure that healthcare providers routinely discuss and offer vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) to their patients, resulting in higher vaccine uptake among adults, better health outcomes, improved population health and cost savings for public and private insurance plans.

CMS is considering removing the Pneumonia Vaccine (Part C) measure from the MA Plan Ratings and moving it to the 2013 display page. Following this transition, the Pneumonia Vaccine measure would no longer be part of the star ratings system used to determine Quality Bonus Payments (QBPs) for MA plans. According to CMS, it “has structured its current star ratings strategy to be consistent with its three-part aim: better care, healthier people and communities, and lower-cost care through improvement.”1 Removing the Pneumonia Vaccine measure from the star ratings system would contradict this three-part aim, as MA plans would no longer have incentives to ensure providers routinely offer pneumococcal vaccination to eligible beneficiaries, thereby undermining both quality of care and the future health of the Medicare population.


CMS cites a “long recall period” as the rationale for removing this measure from the Plan Ratings and transitioning it to the 2013 display page. While no additional clarity was provided by CMS, BIO assumes the measure has failed to produce reliable and valid data due to its reliance on patients’ responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey question regarding receipt of a pneumonia vaccine. However, if the measure has failed to produce quality data, it should be promptly revised or replaced by a better measure based on National Quality Forum (NQF) consensus standards for pneumococcal immunization,2 rather than removed entirely from the star rating system. BIO recommends that CMS work with a quality measure development organization, such as the National Committee for Quality Assurance (NCQA) or the American Medical Association Physician Consortium for Performance Improvement (PCPI) to revise the current measure, replace the current measure with a more appropriate existing measure already endorsed by NQF, or to develop a new pneumonia vaccine measure. CMS may specifically wish to consider NQF measure 0617, High Risk for Pneumococcal Disease - Pneumococcal Vaccination, to replace the current measure. This measure may be able to produce more reliable data than the current measure, and could provide the additional benefit of including populations under 65 years of age at higher risk for pneumococcal disease in the measure population.

CMS has made significant progress toward better patient care and population health by setting standards for improving quality measurement and reporting systems and implementing value-based purchasing programs. The agency is expanding influenza and pneumonia vaccination measures in the hospital setting, and includes both influenza and pneumonia vaccination quality measures in the measure sets for long-term care (LTC) facilities, Electronic Health Records (EHR) Incentive Programs, and the Physician Quality Reporting System (PQRS). Additionally, CMS recently issued a proposed rule requiring certain Medicare and Medicaid providers and suppliers to offer all patients an annual influenza vaccination.3 In a letter to CMS, BIO commended the agency for taking a major step toward increasing influenza vaccination and reducing influenza morbidity and mortality. 4 BIO also urged CMS to establish a similar vaccination standard for pneumonia. Thus, considering current progress, the removal of the pneumonia vaccination measure from the MA Plan Ratings would represent a step backwards for the agency.

Several federal advisory bodies and strategic plans have called for the development of adult immunization quality measures. The National Vaccine Advisory Committee (NVAC) has recommended that CMS and state Medicaid agencies develop more standardized and harmonized adult immunization metrics, with established goals, targets and appropriate incentives. Also, the National Prevention Strategy, released in 2011, states that, “the provision of evidence-based clinical and community preventive services and the integration of these activities are central to improving and enhancing physical and mental health,” and that, the federal government should “improve monitoring capacity for quality and performance of recommended clinical preventive services.”

The Affordable Care Act (ACA) emphasizes prevention and wellness as well as improvements in the quality of healthcare delivered in the United States. Healthy People 2020 also focuses on prevention, calling for an increase in the percentage of non-institutionalized adults aged 65 years and older who have been vaccinated against pneumococcal disease from 60% in 2008 to 90% by 2020.6 The use of both influenza and pneumonia vaccination quality measures is consistent with the goals of the ACA and Healthy People 2020, as they help improve the quality of care received by patients and ultimately increase vaccine uptake and prevent disease. The benefits of these interlinked measures are evident following the introduction of influenza and pneumonia vaccination performance measures in the Veterans Health Administration (VHA) in 1995. Among eligible adults, influenza vaccination rates increased from 27% to 70%, and pneumonia vaccination rates rose from 28% to 85%, with limited variability in performance between networks; pneumonia hospitalization rates decreased by 50%, and it is estimated that the VHA saved $117 for each vaccine administered.

As shown by the VHA study, influenza and pneumonia vaccination measures can raise immunization rates and thereby reduce illness and hospitalizations. In Fiscal Year 2013, CMS will be implementing a Hospital Readmissions Reduction Program. Readmissions for individuals originally admitted for pneumonia are one of the 3 initial focus areas for this program. CMS’s proposal to remove the pneumonia vaccination measure from the star rating system could hinder the goal of this program, as vaccination serves as an effective means to reduce hospital admissions and readmissions.

In light of the aforementioned factors, particularly the importance of pneumonia vaccination in the Medicare population and the ability of quality measures to drive uptake, BIO requests that CMS reconsider its plan to transition the pneumonia vaccination measure to the 2013 display page without replacing it with a substitute measure in the Plan Ratings.


The exclusion of a pneumococcal vaccination measure in the star rating systems for MA plans could adversely affect uptake of the vaccine, which is recommended for all people age 65 and older, and all high risk Medicare patients under 65. This, in turn, would negatively impact the quality of care received by Medicare Advantage beneficiaries and the overall health of the elderly population. CMS stated that it “is committed to continuing to improve the Part C and Part D quality performance measurement system to increase focus on beneficiary outcomes, beneficiary satisfaction, population health, and health care efficiency.” To achieve these goals, the quality performance measurement system should continue to include a pneumonia vaccination measure, as well as other measures for ACIP-recommended vaccines.

BIO appreciates the opportunity to comment on the proposed methodology for 2013 star ratings for Medicare Advantage and Prescription Drug Plans in advance of the final 2013 Call Letter. We look forward to continuing to work with CMS to address these critical issues in the future. Please contact me if you have any questions or if we can be of further assistance. Thank you for your attention to this very important matter.