Annals of Long Term Care

Today’s long-term care (LTC) providers have an increasing myriad of vaccines available for their LTC residents—treatments with critical clinical benefits, especially for older adults. At the same time, accessing these treatments is not always easy, leaving many patients unable to receive those benefits and making it difficult for providers to reap the associated direct and indirect financial incentives tied to vaccine use. These financial incentives are delivered through the Physician Quality Reporting System (PQRS)—Medicare’s voluntary reporting program—and through newer reimbursement models, such as accountable care organizations (ACOs), which provide bonus payments based on specific outcomes.

Many of the target outcomes were derived from clinical guidelines developed by specialty societies and organizations such as the Centers for Disease Control and Prevention (CDC)¹ and the Immunization Action Coalition.² Although these guidelines are appropriate for many older adults, clinical exceptions do exist. The way outcomes are measured neglects to countenance these exceptions, and this places an additional burden on geriatric providers to ensure that they reach every patient for whom these treatments are appropriate.

Achieving target outcomes begins with understanding current clinical guidelines and coverage rules so that the “right” patients are identified and have access to the appropriate vaccines. Given the variety of treatment sites and infrequent dosing of many vaccines, tracking systems are needed to assure that none of these “right” patients are overlooked.

Quality Measures

Under the PQRS, Medicare distributes bonus payments to providers who achieve better than an 80% rate on at least three quality measures that were established based on current clinical guidelines. The Patient Protection and Affordable Care Act of 2010 made several changes to the PQRS.³ In 2011, providers who reported on designated quality measures were eligible for a bonus payment totaling 1% of allowable Medicare Part B fee-for-service charges (FFS). For 2012 through 2014, the bonus payment amount decreases to 0.5%. In addition, physicians who meet the Centers for Medicare & Medicaid Services (CMS’) maintenance of certification criteria are eligible for an additional 0.5% from 2011 to 2013. Beginning in 2015, the PQRS becomes mandatory and instead of rewarding compliant providers with bonus payments, providers who do not successfully report on quality measures will incur a penalty of 1.5% of allowable FFS charges; the penalty imposed increases to 2% for 2016 and beyond.

The three measures can be satisfied just by focusing on vaccines, with the PQRS outlining the following targets for vaccination:

- Preventive Care and Screening: Pneumonia vaccination for patients 65 years and older

- Percentage of patients 65 years and older who have ever received a pneumococcal vaccine

- Preventive Care and Screening: Influenza immunization for patients 50 years and older

- Percentage of patients 50 years and older who received an influenza immunization during the flu season (September-February)

- End-Stage Renal Disease (ESRD): Influenza Immunization in patients with ESRD

- Percentage of patients 18 years and older with a diagnosis of ESRD who received an influenza vaccine at a visit for dialysis between October 1 and February 28, or who reported having previously received an influenza immunization.

Currently, the provider’s rate of PQRS compliance with a specified measure is the percentage of his or her patients eligible to receive the measure or outcome who successfully do so. Within a specific geriatric practice, some patients who appear to meet eligibility criteria for a measure may not be appropriate candidates for the specified outcome, yet current PQRS calculation methods do not accommodate these exceptions. As a result, providers must work especially hard to ensure that every older patient for whom a particular measure is appropriate achieves the target outcome.

The PQRS is not the only set of quality measures that geriatric providers face; the CMS’ Minimum Data Set, Version 3.0 (MDS 3.0), tracks vaccination rates and other quality measures. Specific questions regarding influenza and pneumococcal vaccines are found within Section O: Special Treatments, Procedures, and Programs of the MDS. In contrast to the PQRS, the MDS 3.0 allows certain nursing home residents to be excluded from the quality measures, such as those who have medical contraindications or who decline the proffered treatment. Managed care organizations, such as ACOs, are increasingly applying measures tracked by the PQRS and MDS 3.0 as a means of encouraging appropriate care, especially those measures likely to reduce avoidable medical expenses.

The quality measures, including those related to immunization, stem from accepted best practices that derive from recognized clinical guidelines provided by organizations such as the CDC. Table 1 outlines the CDC’s current immunization recommendations for older adults.¹ Given the advanced age of the typical LTC resident, most of the CDC recommendations on vaccination will apply to the majority of residents. It is up to LTC providers to make sure patients for whom the recommended vaccinations are appropriate receive them.