08/20/2018 - The Academy submitted legislative solutions (see letter below) about health care delivery models, including the use of alternative payment models, to improve care and lower costs for consumers, to the new (or recently-formed) U.S. House Health Care Innovation Caucus. The Academy believes that changes in health care delivery and payment should ultimately result in a marketplace of diverse payment models that incentivize and enable the delivery of the right care at the right time. Reforms must also guarantee a payment landscape that is financially viable for all providers of evidence-based care.
Letter From the Academy
August 15, 2018
|The Honorable Mike Kelly
Health Care Innovation Caucus
Washington, DC 20515
|The Honorable Ron Kind
Health Care Innovation Caucus
Washington, DC 20515
|The Honorable Markwayne Mullin
Health Care Innovation Caucus
Washington, DC 20515
|The Honorable Ami Beri
Health Care Innovation Caucus
Washington, DC 20515
Re: Health Care Innovation Caucus Response for Information
Dear Congressmen Kelly, Kind, Mullin and Bera:
The Academy of Nutrition and Dietetics appreciates the opportunity to provide input to inform the efforts of the bipartisan Health Care Innovation Caucus to advance strategies, including the use of alternative payment models, to improve care and lower costs for consumers.
Representing more than 100,000 registered dietitian nutritionists,1 nutrition and dietetics technicians, registered and advanced-degree nutritionists, the Academy is the largest association of nutrition and dietetics practitioners and is committed to a world where all people thrive through the transformative power of food and nutrition.
Academy members work in a variety of clinical and community settings across the continuum of care and play a key role in shaping the public’s food choices, improving people’s nutritional status, and preventing and treating chronic disease. We work with leaders to find non-partisan public policy solutions that promote health and reduce the burden of chronic disease through nutrition services and interventions. The Academy agrees that changes in health care delivery and payment should ultimately result in a marketplace of diverse payment models that incentivize and enable the delivery of the right care at the right time. Reforms must also guarantee a payment landscape that is financially viable for all providers of evidence-based care.
RDNs independently provide professional services such as medical nutrition therapy2 under Medicare Part B and are recognized as Eligible Clinicians3 in Medicare’s Advanced Alternative Payment Models under Track Two of the Quality Payment Program. The Academy has been a Health Care Payment Learning and Action Network Committed Partner since 2016.4 The Department of Health and Human Services launched the LAN (through CMS) in March 2015 to align public and private sector stakeholders’ efforts to accelerate the adoption of value based payments. The LAN provides a forum for generating evidence, sharing best practices, developing common approaches to the design and monitoring of APMs, and removing barriers to health care transformation across the U.S. health care system.5 MNT provided by RDNs is a widely recognized component of medical guidelines for the prevention and treatment of heart disease, hypertension, diabetes, renal disease, obesity, and many other chronic diseases and conditions, as well as in the reduction of risk factors for these conditions.6 Despite CMS’ focus on value-based care, cost-effective interventions provided by RDNs remain significantly underutilized.
Value-Based Provider Payment Reform
Academy members provide MNT and may provide other services “incident to” physicians in organizations participating in the Center for Medicare and Medicaid Innovation Center Models such as the Comprehensive Primary Care Plus, Transforming Clinical Practice Initiative and the Oncology Care Model. RDNs also provide care in various Accountable Care Organizations, as well as in organizations participating in CMS State Innovation Models. In addition to linking payments to outcomes, APMs should also reduce barriers to care by enabling more flexibility in the personnel and services provided. To date, the APMs employed in these arrangements have not yielded robust improvements in consumer access to evidence-based MNT. There is an opportunity to leverage effectiveness data to improve outcomes as MNT has been demonstrated to reduce blood sugars throughout the diabetes continuum of care.7,8,9 “One study of over 18,000 people with diabetes revealed that only 9.1% had at least one nutrition visit within a 9-year period of time.”10 The Academy recommends that the Health Care Innovation Caucus identify actions that will require the CMS Innovation Center to include and measure the impact of nutrition intervention on outcomes and the total cost of care in the Innovation Models, as well as encourage and enable the health care system to leverage cost-effective non-physician providers as a strategy for advancing value-based health care services.
What barriers in each of the following areas limit the full potential of innovation in Medicare and Medicaid?
Prospective payments to primary care practices are still vastly insufficient to enable transformation that will allow primary care to prevent the complications of chronic disease and related avoidable costs.11 These inadequate primary care payments prevent practices from having inter-professional teams that include qualified providers trained to address multiple conditions in the primary care setting. Increasing the allocation of health care payments for primary care in all models should be a priority of policy makers.
Policy and regulations related to place of service, eligible billing provider and date of service can prevent consumer access to cost-effective care, even for consumers receiving care in organizations participating in CMS Innovation models.
Medicare beneficiaries that have obesity have limited access to a covered benefit, Intensive Behavioral Therapy (IBT) for Obesity. “The first and second most expensive medical diseases in the U.S. have a common denominator—obesity. The healthcare cost for diabetes and ischemic heart diseases in 2013 were estimated at $101 billion and $88 billion, respectively. Obesity is not only associated with these two diseases, but also with stroke, hyperlipidemia, hypertension, asthma, several cancers, and musculoskeletal conditions.”12 If the primary care or gynecology practice does not have the qualified personnel on staff, and/or if the providers do not possess the competencies to effectively provide IBT, treatment is not provided. According to CMS claims data, 99,600 distinct Medicare beneficiaries received IBT services in 2016.13 RDNs are considered qualified auxiliary personnel who can furnish the IBT benefit under the conditions specified in regulations at 42 CFR Section 410.26(b)14 but are not recognized as billing providers. If practices participating in CMS Innovation Models could leverage qualified providers in the greater medical neighborhood, it would improve access to care and outcomes. Studies have shown that primary care practitioners are limited in time, training, and skills to conduct the most effective, high-intensity interventions. The Institute of Medicine in 2000 "rate[d] dietary counseling performed by a trained educator such as a [registered] dietitian as more effective than by a primary care clinician.”15 This is also more cost-effective, as RDNs are paid at 85% of the physician fee schedule.
Other barriers regarding reimbursement negatively impact Medicare beneficiaries with diabetes. Medicare beneficiaries with diabetes cannot receive MNT provided by a RDN and Diabetes Self-Management Training on the same day, nor can beneficiaries visit their doctor and attend DSMT classes on the same day. These are additional examples of how rules in fee for service still influence how and when care can be provided. Medicare beneficiaries with diabetes ultimately must make more trips to access care, even when consumers are receiving care in organizations using APMs.
Lastly, the most significant policy and regulatory barrier related to MNT is that the National Coverage Determination policy prevents Medicare beneficiary access to MNT for prediabetes, cardiovascular disease, cancer, malnutrition, gastrointestinal disease and other conditions.16
How can Congress help the Centers for Medicare and Medicaid Services Innovation (CMMI) achieve its purpose of developing and testing innovative payment and delivery models?
Direct the agency to include nutrition services provided by qualified professionals in CMMI innovation models. Meaningful reform must result in a health care system that includes a systemic implementation of national, evidence-based guidelines for preventing chronic diseases from developing or progressing, including access to covered services delivered by demonstrably effective experts, such as RDNs. Congress should encourage and ensure adequate resources for CMMI to identify specific services (e.g., nutrition services provided by RDNs or other qualified provider) that should be included in a minimum benchmark for team-based care, conduct longer term comparative effectiveness evaluations, especially when considering the use of lay health workers to provide more services. It is imperative to know the cost of effective team-based care and the long term outcomes of the innovation models, as they will inform policy and have an impact on the total cost of care for years to come. Congress also should continue to allocate sufficient funding to CMMI in annual appropriations in order to answer important questions about health care delivery and payment.
Urge CMMI to leverage existing evidence supporting clinically-effective and cost-effective services provided by non-physician providers, including MNT provided by RDNs. The cost of delivering evidence-base care by other providers should be understood in order to inform the development of APMs and the total cost of care. MNT is one example of an underutilized and cost effective service.17 The payments to providers from Alternative Payment Models should be sufficient to support the services needed to improve care.18 To ensure consumer access to services provided by non-physician providers in an APM environment, it is essential to understand the cost of providing that care. This will allow organizations and practices to accurately account for the cost of that care for use in the development of episode-based payments, bundled payments and population based payments.
Act on opportunities to “fix” legislation and policies to better-align with the goals of value-based care
Legislative fixes could go a long way to improving access to cost effective care for consumers receiving care in organizations and practices participating in various delivery and payment models. The Treat and Reduce Obesity Act (H.R. 1953), sponsored by Caucus co-chair Rep. Kind, is one example of an opportunity to remedy the regulatory barriers associated with consumer ability to access to care and allow RDNs and other qualified providers to be able to provide, and be reimbursed for providing services associated with the IBT benefit.
Two additional opportunities of existing legislation that would improve access to cost-effective care include the Expanding Access to Diabetes Self-Management Training Act and the Preventing Diabetes in Medicare Act. The Preventing Diabetes in Medicare Act, H.R. 3124/S. 1299 would allow Medicare coverage of medical nutrition therapy provided by registered dietitian nutritionists for patients with pre-diabetes. There are Medicare beneficiaries with prediabetes who may not qualify for the new Medicare Diabetes Prevention Program (e.g., have normal body weight or may have below normal body weight) or may have multiple co-morbidities requiring expertise beyond what non-RDN providers in the MDPP may be able to safely provide. Beneficiaries should be provided with multiple options to prevent this costly chronic disease.
The Expanding Access to Diabetes Self-Management Training in Medicare Act, H.R. 5768 would remove existing barriers to Diabetes Self-Management Training and improve utilization. This bill would remove red tape by:
- Allowing beneficiaries to receive valuable services (MNT and DSMT) on the same day;
- Permitting physicians and qualified nonphysician practitioners who are not managing an individual’s diabetic condition, but who are acting in coordination with the physician or qualified nonphysician practitioner managing the individual’s diabetic condition to order DSMT services;
- Extends the initial 10 hours of DSMT covered by Medicare beyond the first year until fully utilized. In addition, allows an additional 6 hours (or greater if determined appropriate by the Secretary) of DSMT services during the year in which the initial 10 hours are exhausted, if there is a determination of medical necessity;
- Removes Part B cost-sharing for DSMT services and excludes DSMT from the deductible requirements.
What is the ultimate destination of the movement to value in the Medicare program?
The ultimate destination from movement to value in the Medicare program should be a system where most care is planned, enabling the right type of care and services with high-value providers to be delivered in the most cost effective setting with deference and consideration for patient and family needs. There must be choices for consumers that include small practices, large systems, as well as independent physician and non-physician providers to ensure a robust healthcare workforce to meet the needs of a growing Medicare population. There are risks of decreased consumer choice as consolidation of practices and systems occurs in response to the changing financial dynamic. In the near future, the CMS Physician fee schedule will not keep pace with the cost of doing business and inflation, and this presents a significant risk for independent physician and other health professional practices (including RDNs) that cannot take on significant downside risk of APMs. The changes in the fee schedule are designed to incentivize participation in APMs; however there needs to be some remedy to protect physicians, small practices and independent providers who play an important role in providing care, and who will not be able to meet Medicare’s requirements to participate in any of the options under Medicare’s Quality Payment Program. RDNs are an example of cost effective providers who provide important services to Medicare beneficiaries, who will most likely be unable to meet the minimum volume threshold requirements to qualify as Eligible Clinician for the Merit Based Incentive Payment Program. This is an example of the unintended consequences of CMS policies on many providers. Without a fix to the CMS Physician Fee Schedule for small and independent providers, the nation risks losing even more primary care physicians.
Thank you for the opportunity to inform the Health Care Innovation Caucus’ efforts to ensure that Americans have access to good care at an affordable price. The Academy recognizes the complexity in developing legislative solutions for this vulnerable population and we offer our assistance and evidence analysis as the Caucus moves forward in the process. Please contact either Jeanne Blankenship by telephone at 202/775-8277, ext. 1730 or by email at firstname.lastname@example.org, or Marsha Schofield at 312/899-1762 or by email at email@example.com with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Vice President, Policy Initiatives & Advocacy
Academy of Nutrition and Dietetics
Marsha Schofield, MS, RD, LD, FAND
Senior Director, Governance
Academy of Nutrition and Dietetics
1The Academy has approved the optional use of the credential “registered dietitian nutritionist (RDN)” by “registered dietitians (RDs)” to more accurately convey who they are and what they do as the nation’s food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process. The provision of MNT (to a patient/client) may include one or more of the following: nutrition assessment/reassessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation that typically results in the prevention, delay or management of diseases and/or conditions. [Academy of Nutrition and Dietetics’ Definition of Terms list updated May 2017. Accessed July 19, 2018.
3APMs Overview, accessed August 15, 2018.
4HCP LAN Committed Partners accessed August 8, 2018
6Grade 1 data. Academy Evidence Analysis Library, [Grade Definitions: Strength of the Evidence for a Conclusion/Recommendation Grade I, “Good evidence is defined as: “The evidence consists of results from studies of strong design for answering the questions addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of serious doubts about generalizability, bias and flaws in research design. Studies with negative results have sufficiently large sample sizes to have adequate statistical power.”
7UK Prospective Diabetes Study (UKPDS) 7. Response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients. Metabolism. 1990; 39:905-912.
8Coppell/LOADD study, cited by Franz M, Boucher J, Evert A. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014: 7; 65-72
9Johnson R. The Lewin Group. What does it tell us, and why does it matter? J Am Diet Assoc. 1999; 99: 426-427.
10Franz M, Boucher J, Evert A. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2014;7:65-72.
11 Basu, S., Phillips RS, Song Z., Bitton A., and Landon, B. “High Levels of Capitation Payments Needed to Shift Primary Care Toward Non Visit Team and Proactive Care.” Health Affairs, Vol 36 No 9 (2017) 1599-1605.
12Trevino, R.P., Pina, C., Fuentes, J.C., and Nunez, M. “Evaluation of Medicare’s Intensive Behavioral Therapy for Obesity: the BieneStar Experience” Am J Prev Med 2018;54(4):497–502.
13Medicare Provider Utilization and Payment Data: Physician and Other Supplier PUF CY2015 Accessed August 10 2018
14 Intensive Behavioral Therapy (IBT) for Obesity accessed August 8, 2018.
15Committee on Nutrition Services for Medicare Beneficiaries, Food and Nutrition Board. of the National Academy of Science, The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population; 2000, p11.
17Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 2008.
18The Alternative Payment Model Framework Accessed August 8, 2018.