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HEALTHY OUTCOMES
THROUGH PREVENTION EFFORTS

No Shot
in the Dark
Boosting Adult Vaccination Rates
Through Practical CMS Tactics
A HOPE Working Group White Paper
The views and opinions expressed in this paper are those of the
authors and do not necessarily reflect the official policy or position
of any other agency, organization, employer or company.
This research was made possible through generous sponsorship
from Pfizer.

James Appleby
Executive Director & CEO
The Gerontological
Society of America
Marla Dalton
Executive Director & CEO
National Foundation for
Infectious Diseases (NFID)
Elizabeth Sobczyk
Senior Program Manager,
Strategic Alliances
The Gerontological
Society of America
L.J. Tan, Ph.D.
Chief Strategy Officer
Immunization Action Coalition
Jacque Thornton
Sr. Vice President
LeadingAge Georgia

No Shot in the Dark: Boosting Adult Vaccination Rates Through Practical CMS Tactics

Introduction

T

he U.S. healthcare system currently stands under incredible pressure. The grinding national debate about
costs and coverage has hit new highs (or lows), and
the policy conversation has become centered on questions of
who pays for what and how much. The answers to these questions
are essential and this debate must occur.
Yet a broader view of healthcare in the U.S. brings into perspective two deeper, more fundamental developments that,
if left unaddressed, will doom any ostensible solutions for
payment and coverage.
First, the U.S. population is growing older, and life expectancies that were once rare have become the norm. As we
live into our 80s, 90s, and even 100s, we require more and
costlier care. In other words, our changing demographics
have increased the demand for health care services, and the
subsequent supply carries a ledger. Second, thanks to decades
of breakthrough innovations and developments, treatments
that were not long ago viewed as “miracles” have become
standard practices. These miracles are indeed saving countless lives – but they’re not free.
Looking ahead, these pressures are not likely to abate.
We will continue to grow old. Innovation will march on.
And the debates about coverage and costs will continue.
Therefore, a more sustainable approach to curbing costs
among an aging population is needed.
In the spirit of searching for new solutions, we formed
the HOPE Working Group (Healthy Outcomes through
Prevention Efforts), a diverse alliance of expert stakeholders
from a range of cross-disciplinary and cross-sector perspectives. Convening initially in August 2017, we saw prevention
as a solution to the tough problems plaguing healthcare.
A “prevention approach” would be a way to save lives and
improve well-being while also reducing costs.
It would be naïve, of course, to claim that this was a breakthrough insight or that the value of prevention has not been
discussed at length by policymakers, academics, and other
experts in the field. Nevertheless – and perhaps as a result – t he

HOPE Working Group

In the spirit of searching for new solutions,
we formed the HOPE Working Group
(Healthy Outcomes through Prevention
Efforts), a diverse alliance of expert
stakeholders from a range of crossdisciplinary and cross-sector perspectives.

260,000

The number of deaths in the
US each year attributed to
preventable causes4

84%
More than 84% of eligible
adults don’t take advantage of
the no-cost Medicare Annual
Wellness Visit 5

60%
More than 60% of older
adults have not received a
pneumococcal vaccine7

80%
Eighty percent of older
adults have not received a
Tdap vaccine.6

66%
Sixty-six percent of older
adults have not received a
shingles vaccine 8

2

No Shot in the Dark: Boosting Adult Vaccination Rates Through Practical CMS Tactics

WHY ADULT VACCINATION

Efficacy

Savings

Availability

Vaccines have proven effective at
decreasing hospitalizations and medical
visits,9 improving quality of life, and
reducing morbidity and mortality.10

The four most prevalent vaccinepreventable diseases in older adults—
influenza, pneumococcal disease,
shingles, and whooping cough—cost the
U.S. $26.5 billion each year. Increasing
rates of adult vaccination can dramatically
decrease this burden.11

Vaccines can be obtained in a variety
of locations beyond doctor’s offices,
including pharmacies, grocery stores,
workplaces, and community-based clinics.
In fact, in the U.S., more adult patients
today receive flu vaccines in pharmacies
(28%) than in doctors’ offices.12

HOPE Working Group convened to identify and chart out
practical, implementable solutions within the framework
of prevention.

measure up to the challenges we face. If we focus only on
new ideas, we would risk leaving some of the best
ones behind.

After much discussion, our focus lasered in on adult vaccination, particularly around how the Centers for Medicare and
Medicaid Services (CMS) can improve both access to, and administration of, recommended adult vaccines. As the nation’s
largest payer – w ith 59 million older adults (65+) covered1,
surpassing United Health Group, the largest private payer
in the U.S., by 53% 2 – CMS is uniquely positioned to influence the adult vaccination space. As one healthcare observer
puts it, CMS can “influence not just the flow of billions of
dollars…but also the way hospitals, nursing homes, and other
providers treat patients.”3

In this paper, we intend to fuse the old with the new to spur
ongoing, constructive dialogue about the needs and opportunities for greater preventative healthcare. We look forward to
new discussion and collaboration to achieve this vision.

If the question at hand is how to improve prevention broadly
and vaccination specifically, a logical starting place is CMS.
What we offer in this paper is by no means a final solution to
the forces weighing on U.S. healthcare, but we do think that
CMS could substantially “move the needle” on prevention
through strategic steps that will ultimately improve adult
vaccination rates. We share these ideas in this paper.
Specifically, we explore the context, evidence, and suggested
changes for a set of CMS recommendations, and we suggest
practical steps that CMS could take to enhance a prevention
mindset through adult immunization.
We concede that while some of these ideas may have been
tried before with unsuccessful results, setbacks cannot doom
us. The stakes are too high, and our collective tenacity must

HOPE Working Group

Signed,
James Appleby
Executive Director & CEO,
The Gerontological Society of America
Marla Dalton
Executive Director & CEO,
National Foundation for Infectious Diseases (NFID)
Elizabeth Sobczyk
Senior Project Manager, Strategic Alliances,
The Gerontological Society of America
L.J. Tan, PhD
Chief Strategy Officer,
Immunization Action Coalition
Jacque Thorton
Sr. Vice President,
LeadingAge Georgia
The views and opinions expressed in this paper are those of the authors
and do not necessarily reflect the official policy or position of any other
agency, organization, employer or company.

3

No Shot in the Dark: Boosting Adult Vaccination Rates Through Practical CMS Tactics

A Framework for Further
CMS Action: 4 Pillars

I

n developing the recommendations laid out in this
paper, one question remained at the center of our
thinking: “How could CMS spread the benefits of adult
vaccination to the widest possible population of patients and
healthcare stakeholders?”

The answers to this question were informed not only by our
professional experience in various fields but also through
supplementary research. We set out to find proven healthcare models as well as CMS programs that provide replicable
solutions based on evidence. In particular, we focused on
solutions that either had been or could be adapted to the
specific needs of adult vaccination. We also considered some
remarkable ideas that never made it to life.
Ultimately, we believe there are four pillars that can set the
framework for recommended CMS actions to improve vaccination rates among older adults.
The remainder of this paper explores the opportunities within each of these four pillars. While not all the ideas are new,
in combination, these ideas have new power – and may help
move stagnant vaccination rates.

PILLAR ONE

Better Data and
Information Sharing
PILLAR TWO

Enhance Provider, Payer,
and Patient Alignment on
Existing CMS Policies
PILLAR THREE

Community Engagement
for People of Color
PILLAR FOUR

Vaccination in
Non-Traditional Sites

HOPE Working Group

4

No Shot in the Dark: Boosting Adult Vaccination Rates Through Practical CMS Tactics

PILLAR ONE

Better Data and
Information Sharing

WHERE WE ARE TODAY

T

he systems in place that record and share information
about adult vaccinations in the U.S. are complex and
fragmented. Record-keeping systems vary widely, and,
as a result, they can be difficult to share between providers.
Too often, finding all the pieces of an adult’s vaccination
record is difficult, if not impossible.
There are three primary reasons why vaccination data is
neither up-to-date nor easily accessible. First, the systems that
store the data don’t do a good enough job “talking” to each
other, and often one system can’t share its data with another.
As a result, a provider often will not have access to a patient’s
vaccination history, even though that history is stored in a
data system, somewhere.

HOPE Working Group

We need a set of solutions that improve
data sharing, incentivize providers to
input data, and empower patients to
take ownership of their own vaccine needs
and history.
Second, healthcare providers often do not input a patient’s
vaccination history into existing state-wide databases. And
why would they? As one provider noted: If the system doesn’t
work, why bother to add data to it? This attitude may not be laudable, but it is certainly understandable – and representative.
Adding a patient’s vaccination data to a system takes time
and may not always be simple; it’s an “ask” in a busy provider’s day. And if the end-result isn’t beneficial, then many don’t
see the need to bother.

5

No Shot in the Dark: Boosting Adult Vaccination Rates Through Practical CMS Tactics

Third, patients move in, out, and through the healthcare
system. With new jobs come new insurance plans; with relocations come new doctors, pharmacies, and health systems.
In the U.S., a particularly mobile country, the movement of
people within and across state lines creates another challenge
for immunization record-keeping.
To solve these growing problems, we need a set of solutions
that improves data sharing, incentivizes providers to input
data, and empowers patients to take ownership of their own
vaccine needs and history.
RECOMMENDATIONS
1

Improve the ability of
Immunization Information
Systems (IIS) and Electronic
Health Records (EHR) to work
together

According to the Centers for Disease Control and
Prevention (CDC), an IIS is designed to “help providers and
families by consolidating immunization information into one
reliable source.” It is a “computerized database that records
all immunization doses administered by participating providers.”13 Much of the literature reporting on the usefulness
of an IIS focuses on how the system can both track and keep
current vaccination records for infants and children, even as
they switch providers, systems, and geographies. While these
systems have been vital to the success of childhood vaccination, their full potential for adult vaccination has
been unrealized.
CONTEXT:

While IIS registries have been vital to
the success of childhood vaccination,
their full potential for adult vaccination
has been unrealized.
The reasons why are varied. For example, IIS registries are
regulated at the state and sometimes local level, thus complicating the possibility of effective federal policy. Further,
IIS registries work on different operating systems, require
different types of patient consent, and vary by extent of
availability (with Rhode Island and Connecticut, for example,
offering no IIS options for adults). Each of these barriers
limits the potential of IIS registries, yet none of them are the
most significant.

HOPE Working Group

The biggest opportunity to realizing IIS capabilities with
adult vaccination is finding a strategy for enabling different
IISs to interface seamlessly with EHRs. Indeed, for IISs to
reach their potential with adult immunizations, they would
need to enable bidirectional communication abilities with
EHR systems. If they could, providers would be able to both
send new records and request record histories from the IIS.
This functionality would transform the usefulness of the IIS
and the providers’ ability to access and update an individual’s
vaccination history.
EVIDENCE: The need for communication and information-sharing between an IIS and an EHR is well understood.
In 2009, as part of the American Reinvestment and Recovery
Act (ARRA) – or what is widely known as the “stimulus package” – t he Medicare and Medicaid EHR Incentive Program
was launched. It was designed to “provide financial incentives
for the meaningful use of certified EHR technology, [and it]
focused on the interoperability between immunization information systems and EHRs.”14

More specifically, the “stimulus package” focused on EHR
functionality; the goal was to get these private systems to
better provide public health functionality to physicians and
other providers. This was no small task. EHRs were designed
to manage billing and record-keeping for individual health
systems and providers, not necessarily to function as public
health tools.

Only 8% of general internists and
36% of family medicine practitioners
reported recording adult immunization
information in a state or regional IIS.
While progress has been made, there are clear next steps that
could better utilize the IIS and EHR systems that are built
and currently in place.
CMS can encourage better collaboration between IISs and EHRs.

SUGGESTED ACTION:

First, CMS could promote the interfaces that enable different IISs and EHRs to “talk” to one another. Although an
increasing number of IIS and EHR systems have bidirectional communication capabilities through the industry-standard
HL7 messaging (currently at 67%), this exchange depends
on the technical capacities of each state and EHR system.15
This investment in increasing bidirectional communication between IIS and EHR systems would establish the IIS
as the central database of vaccine information, and enable

6

No Shot in the Dark: Boosting Adult Vaccination Rates Through Practical CMS Tactics

According to one 2016 survey, “more than 90% [of providers]
reported routinely assessing their patients for vaccinations,
but only 32% reported that their practices submitted adult
vaccination records to the IIS in their state or city.”
physicians to send records to ISS, and to request a patient’s
comprehensive vaccination history.
Second, CMS could provide educational trainings and incentives for providers to be “onboarded” into the appropriate
system so they can enter data in a correct, timely manner.
Only 8% of general internists and 36% of family medicine
practitioners reported recording adult immunization information in a state or regional IIS.16 A survey conducted at the
2013 National Adult and Influenza Immunization Summit
concluded that 40% of providers agreed “lack of awareness”
was the biggest barrier to ISS use.17 Based on basic reimbursement procedures, we know that providers are keeping
track of the vaccines they give. As such, providers would not
need to engage in an entirely new set of behaviors, but modify their current behavior so that data is being entered not
only for reimbursement purposes, but also record-keeping.
CMS could partner with the Adult Vaccine Access Coalition
(AVAC) to educate physicians about the importance of inputting records into the IIS.
2

Launch a pilot study of
vaccine-record financial
incentives for internists

There are currently few financial incentives for
healthcare providers and hospitals to address the barriers in
the medical data system. This lack of incentives fails to align
with recommendations made in the academic literature.
For example, a study published in American Journal of Public
Health observed that creating financial incentives for providers “rapidly increased immunization coverage in medical
records" for childhood immunization.18 This is a lesson that
should shape how we think about opportunities for integrating providers and hospitals into creating a data-sharing and
record-keeping solution.

CONTEXT:

One such opportunity is to encourage all vaccination providers to input records into their state IIS system, when both
legally and technically feasible. This type of record-keeping

HOPE Working Group

is the foundation of an effective data-sharing system, but it
won’t happen on its own. It requires committed record-keeping by providers, which, of course, is an “ask” of their time
and resources. A solution could be an incentives program
that specifically encourages providers to record vaccination
into IIS registries across specialties and healthcare settings.
This type of record-keeping would mark a sea-change in
provider behavior.
According to one 2016 survey, “more than 90% [of providers]
reported routinely assessing their patients for vaccinations,
but only 32% reported that their practices submitted adult
vaccination records to the IIS in their state or city.”19
Given the current levels, there is tremendous opportunity
to encourage better IIS utilization.
A number of studies have shown that CMS
incentives for providers can improve record-keeping. One
example is the Quality Payment Program, which rewards
providers for submitting high-quality data in the form of
payment adjustments. While there is merit to this incentive,
it falls short in that quality vaccination records are not given
priority. This is a shortcoming that can be fixed. The Quality
Payment Program replaced another EHR initiative: the
Medicare and Medicaid EHR Incentive Program. From 2011
to 2016, this program worked with individual providers and
hospitals to incentivize the adoption, implementation, and
upgrading of EHR technology. 20 While there is limited documentation of the results of the EHR Incentive Program, by
2013, more than 300,000 providers had successfully received
payment for participating in the program. 21 The expansion
of the scope of the EHR program – from incentivizing the
adoption and upgrading of EHR technology to the Quality
Payment Program’s emphasis on quality data – indicates that
the Medicare and Medicaid EHR Incentive Program was
successful enough to warrant a program larger in strategy.
EVIDENCE:

CMS could launch a pilot study of
financial incentives to encourage providers to record vaccines. This could include a higher incentive for submitting
adult vaccination records in the Quality Payment Program

SUGGESTED ACTION:

7

No Shot in the Dark: Boosting Adult Vaccination Rates Through Practical CMS Tactics

or creating a separate program specifically for vaccines. In
particular, the pilot program could focus on internists, who
are often the first-line of defense for patients receiving care.
This pilot study could determine whether financial incentives are an effective, worthwhile investment to improve
adult vaccination records. If successful, the pilot could serve
as the first step for the wider rollout of a financial incentive
program. Ideally, this would increase the accuracy and accessibility of vaccine records, helping providers to recommend
vaccines to the right patients and to improve overall vaccination coverage.
3

Cross-reference vaccine
records to create a
patient-reminder system

Many older adults are unaware of what vaccines
they have received and which ones they need. As a result,
only a small percentage of older adults proactively seeks or
requests recommended vaccines. One solution could be a
comprehensive system that both identifies patients who need
vaccines and provides prompts to remind them which vaccines are needed and when.

CONTEXT:

A literature review of 41 studies finds that
patient reminders – such as postcards, letters, and telephone
calls – improved immunization rates. 22 Moreover, these
reminders worked across a variety of different sites, including
academic settings, private practice settings, and public health
clinics.
EVIDENCE:

In particular, text message immunization reminders have
already been found to increase vaccination rates for children
from low-income, urban populations. 23 Given that low-income, urban populations struggle with particularly low adult
vaccination rates, text reminders could be an effective public
health tool.
CMS could build a patient reminder
system that checks available vaccine records and then sends
vaccine reminders to eligible patients. 24 To do this, CMS
could analyze existing claims to determine which patients
have not received vaccines, and then cross-reference those
results with recommended vaccines that are included in the
individual’s Medicare coverage. CMS could then send a patient an automated reminder via an appropriate channel.

SUGGESTED ACTION:

TYPES OF REMINDERS SHOWN TO INCREASE IMMUNIZATION RATES25

Telephone and
autodial calls

Letters

Postcards

Text
messages

Or a combination of these methods

HOPE Working Group

8

No Shot in the Dark: Boosting Adult Vaccination Rates Through Practical CMS Tactics

PILLAR TWO

Enhance Provider, Payer,
and Patient Alignment
on Existing CMS Policies
WHERE WE ARE TODAY

W

hile there is good reason for CMS to consider
new and innovative policies for improving vaccination rates of older adults, it is also important to
consider what policies and programs are already in place. In
looking for opportunities to leverage existing programs, two
ideas emerged: first, providing more robust education and
outreach about the existing CMS coverage of vaccines; and,
second, making the most use of the “Welcome to Medicare”
and Annual Wellness Visits.
Despite the potential of these incentives and programs, they
have been underutilized, resulting in missed opportunities
for intervention.
RECOMMENDATIONS
1

Educate providers about
CMS vaccine reimbursement

Depending on the vaccine, 36-71% of providers
reported not knowing how Medicare covered vaccinations.
Thirty-seven percent were ‘not at all aware’ and 19% were ‘a
little aware’ of vaccine-specific provisions of the ACA. 26 As
a result, providers may not proactively raise the topic of vaccination with adult patients or encourage patients to receive
recommended vaccines. There is a significant opportunity to
inform providers and older adult patients about existing CMS
payment of vaccines.

CONTEXT:

Further, this lack of awareness may prevent the broader
healthcare team from raising vaccines with older adults, even
as part of a larger discussion about preventative healthcare.
The issue here is not with the physicians alone, but of the

HOPE Working Group

office staff and other members of the healthcare team who
could leverage their relationships with patients to encourage
vaccination.
EVIDENCE: Medicare provides different protocols for vaccinations, depending on whether a vaccine falls under Part B or
Part D. These protocols include requiring:

(1) a provider to administer the vaccine and bill the patient,
which can be submitted for reimbursement; (2) the vaccine to
be administered in a pharmacy where it can be directly billed
to Medicare Part D; (3) the provider’s and patient’s Medicare
Part D carrier to register and participate in the Web-based
portal for payment (TransactRx); or (4) a provider to administer the vaccine with a pharmacy billing Part D directly
through a collaborative agreement.27

9


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