Academy Applauds CMS for Adding Coverage for On-line Services under Medicare Part B

September 24, 2019

Ms. Seema Verma, MPH,
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: CMS-1715-P
P.O. Box 8016
Baltimore, MD 21244-8016

Re: File Code- CMS-1715-P; Medicare Program; CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B for Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations

Dear Administrator Verma:

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on File Code- CMS-1715-P published in the Federal Register on August 14, 2019. Representing over 107,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of nutrition and dietetics practitioners committed to accelerating improvements in global health and well-being through food and nutrition. RDNs independently provide professional services such as medical nutrition therapy (MNT)2 under Medicare Part B and are recognized as Eligible Clinicians (ECs) and Qualified APM Participants (QPs) in Medicare's Quality Payment Program. RDNs provide high quality, evidence-based care to patients and deliver substantial cost-savings to the health care system as a whole.

The Academy offers specific comment on the following proposed rule items:

  1. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs)
  2. Principal Care Management (PCM) Services
  3. Consent for Communication Technology-Based Services
  4. Online Digital Evaluation Service (CPT Codes 98X00, 98X01, and 98X02)
  5. CY 2020 Updates to the Quality Payment Program
  6. MIPS Value Pathways RFI
  7. Analysis of the Fee Schedule Impact on Specialties

1. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs)

The Academy commends CMS for its continued efforts to address the opioid crisis in this country. As the agency seeks comment on any items and services currently covered and paid for under Medicare Part B that should be considered to be added to the definition of "opioid use disorder treatment services," the Academy urges CMS to include Medical Nutrition Therapy (MNT) services as a core component of such programs. MNT services provided by RDNs are a critical treatment component for SUDs as these individuals frequently suffer from gastrointestinal issues, flare-ups of previously dormant auto-immune diseases, eating disorders/disordered eating and malnutrition in all its forms.3 This population often also benefits from life-skills training, including grocery shopping, meal planning and preparation, for which RDNs and NDTRs are best qualified to provide. Due to the multi-dimensional nature of opioid treatment programs, including the need to address all the social determinants of health, the Academy believes it is essential that CMS build a payment model that leverages the unique expertise of the full health care team, including RDNs.

In comments to the Centers for Disease Control on Nutrition Interventions and Drug Overdose Response Investigation Data Collections4, we cited several studies documenting substandard eating patterns during drug use, including inadequate intake leading to micronutrient deficiencies5,6,7,8,9,10 and malnutrition.11,12,13,14,15 We also provided extensive evidence to support the claim that nutrition can play a critical role in promoting wellness during the recovery process, thereby helping to reduce relapse and accidental overdose or death. Specifically, we noted:

"Several studies have demonstrated links between nutrition education and positive outcomes in SUD treatment settings [52-57]. Some of the studies have suggested that nutrition education has led to reduced rates of relapse, but higher quality research with greater sample sizes are needed to confirm these findings. Given the opioid epidemic and alarming number of overdose and deaths, however, it seems unwise to wait for more data before using nutrition as an intervention strategy.

Nutrition interventions during recovery may promote abstinence and prevent or minimize the onset of chronic illness, improving resource allocation. A review article from the United Kingdom on the role of healthy eating advice as part of drug treatment in prisons concluded that "substance-misuse is a major factor in recidivism and if this could be reduced through improvement of nutritional status, it could be a cost effective means of helping to tackle this problem" [58]. Given the opioid epidemic, public health measures necessitating nutrition standards in treatment settings should be considered critical. There is a timely need for specialized nutrition expertise in SUD treatment centers, and RDNs are highly qualified for the job."16

While the current Medicare Part B MNT benefit is limited to beneficiaries with diabetes or renal disease, a bundled payment for OTPs offers the opportunity to include vital nutrition interventions to all individuals affected by opioid use disorder, regardless of other medical diagnoses.

2. Principal Care Management (PCM) Services

A gap CMS identified in coding and payment for care management services is care management for patients with only one chronic condition. Therefore, CMS is proposing a separate code and payment for Principal Care Management (PCM) services. The Academy agrees with CMS that payment for care management services is critical to achieving the goals of Better Care, Smarter Spending and Healthier People. We also agree with CMS that patients with a single high-risk disease or complex chronic condition may require significant resources to manage their care, including MNT services provided by RDNs. Data show that MNT provided by an RDN is linked to improved clinical outcomes and reduced costs related to physician time, medication use and hospital admissions for people with obesity, diabetes, and disorders of lipid metabolism, as well as other chronic diseases.17 As CMS looks at ways to support important care management services, the Academy urges CMS to recognize the wide range of qualified non-physician practitioners located outside of the physician office setting who effectively provide such services as part of the patient-centered health care team. These non-physician team members are critical to achieving successful patient and population health outcomes and controlling the progression of chronic disease. Thus, there needs to be a payment mechanism for these essential services that is not exclusively tied to physician providers and/or limits the definition of “clinical staff” to those physically located in and/or employed by the physician office practice. We also recommend that medical record documentation should be required to demonstrate ongoing communication with the patient's primary care provider.

3. Consent for Communication Technology-Based Services

With the intent to reduce burden and promote the use of communication technology-based services, CMS is seeking comment on whether a single advance beneficiary consent could be obtained for a number of communication technology-based services. During the consent process, the practitioner would make sure the beneficiary is aware that utilization of these services would result in a cost sharing obligation. While an annual consent would be easiest on the practitioner, we are concerned that Medicare beneficiaries are faced with signing a great deal of paperwork often from a wide variety of providers and may easily forget what they signed. Therefore, to reduce the likelihood or surprise bills, the Academy supports the concept of a single advance beneficiary consent and recommends requiring it prior to initiation of the first service by a practitioner and then quarterly thereafter.

4. Online Digital Evaluation Service (CPT Codes 98X00, 98X01, and 98X02)

The Academy is pleased that CMS has proposed to cover patient-initiated on-line digital evaluation services provided by non-physician health care professionals. Such coverage would support improved adherence to treatment plans for Medicare beneficiaries with diabetes, chronic kidney disease, and renal transplants. RDNs are increasingly receiving inquiries from patients through a variety of communication technologies about physiological data (e.g., blood glucose self-monitoring results, blood pressure, weight, potassium), medications, physical activity, adverse symptoms and/or food intake related to their nutrition care plan. RDNs make decisions about whether an MNT encounter may be necessary based on these inquiries. Often a virtual check-in offers the opportunity to make simple adjustments in a nutrition care plan that helps to avoid higher cost encounters with the health care system (e.g., hospitalizations, emergency department or urgent care center visits) and/or additional long distance trips to health care professionals for patients located in rural areas.

The Academy urges CMS to finalize coverage of these services in the Final Rule at the RVUs recommended by the RUC HCPAC. It is unfortunate that CMS did not raise concerns with the terminology in the codes at the time they were presented to the CPT as it could have avoided the burden of having CPT codes and HCPCS code for the exact same service. The Academy echoes the comments submitted by the RUC HCPAC regarding these codes:

“The CPT Editorial Panel created a separate set of codes for non-MD/DOs who are unable to report services within the Evaluation and Management section of CPT for online services. The CPT language reads 98X00-98X02 "Qualified nonphysician health care professional digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the 7 days: …." CMS states that the codes may not be utilized because the term “evaluation and management” is included in the code descriptor. CMS has proposed a set of G codes, GNPP1-GNPP3 with the following language "Qualified nonphysician health care professional online assessment for an established patient, for up to seven days, cumulative time during the 7 days: …." It is unfortunate that this issue with terminology was not raised prior to the Proposed Rule as the CPT Editorial Panel could have easily made the editorial change in time for the CPT 2020 publication and avoid the burden of having two sets of codes to describe the same service. The CPT Editorial Panel will consider this editorial change for CPT 2021, so the CPT codes can be utilized, rather than G codes, as intended.

CMS is proposing a work RVU of 0.25 for CPT code GNPP1, which reflects the HCPAC recommended work RVU for CPT code 98X00. For HCPCS codes GNPP2 and GNPP3, CMS believes that the 25th percentile work RVU associated with CPT codes 98X01 and 98X02 respectively, better reflects the intensity of performing these services, as well as the methodology used to value the other codes in the family, all of which use the 25th percentile work RVU. Therefore, CMS is proposing a work RVU of 0.44 for HCPCS code GNPP2 and a work RVU of 0.69 for HCPCS code GNPP3.

98X01/GNPP2
The HCPAC recommends that CMS accept the survey median work RVU of 0.50 for CPT code 98X01 because this maintains the same relativity as equivalent physician codes, 9X0X1-9X0X3. CMS should focus on the relativity of these services not the survey data point used. The work and time required by the physician or qualified nonphysician health care professional to provide these services are the same. The description of intra-service work for 98X01 and 9X0X2 is essentially the same. CPT code 98X01 should be valued at 0.50 work RVUs because it is similar to 98967 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion (work RVU = 0.50). The HCPAC noted that these services require the same QHP intra-service time to perform. The HCPAC deemed the survey conducted by the specialty society to be robust with survey respondents consistently reporting the overall time/intensity of 98X01, as well as all of the individual work components, as identical to or more intense than 98967 (the key reference service code). 98X01 is more intense than 98967 because the QHP response is documented in writing. There is a higher risk and challenge within the written response, as the QHP or patient may misinterpret something within the communication. Whereas, with a telephone call, any misinterpretations would be clarified with immediate feedback. Additionally, 98X01 is more complex because the QHP may review multiple images some of which may be hard to decipher, as well as engage in multiple communications over seven days which adds to the intensity of this service. The HCPAC urges CMS to accept a work RVU of 0.50 for CPT code 98X01.

98X02/GNPP3
The HCPAC recommends that CMS accept a work RVU of 0.80 for CPT code 98X02 because this maintains the same relativity as the equivalent physician codes, 9X0X1-9X0X3. CMS should focus on the relativity of these services not the survey data point used. The work and time required by the physician or qualified nonphysician health care professional to provide these services are the same. Once again, we note that the nonphysician healthcare professional work for this service is equivalent to the physician work for 9X0X3. CPT code 98X02 should be valued at 0.80 work RVUs because it is similar to 98968 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion (work RVU = 0.75 and 25 minutes intra-service time, 36 minutes total time). The HCPAC noted that 98X02 requires more qualified nonphysician health care professional work to perform and is more intense than 98968 because it describes 21 minutes or more, rather than a range of 21-30 minutes. The service will likely require more than 21 minutes, potentially much more. Additionally, the typical patient receiving 98X02 has problems and concerns greater than the average patient. The HCPAC Review Board agreed that 98X02 is more intense than 98968 because the qualified nonphysician health care professional response is documented in writing with higher risk and challenges with multiple communications, not a verbal response with immediate clarifications as with CPT code 98X00. The HCPAC deemed the survey conducted by the specialty society to be robust with survey respondents consistently reporting the overall time/intensity of 98X02, as well as all of the individual work components, as identical to or more intense than 98968 (the key reference service code). The HCPAC urges CMS to accept a work RVU of 0.80 for CPT code 98X02."

5. CY 2020 Updates to the Quality Payment Program (QPP)

Quality Performance Category
CMS is proposing several changes in measures under the Quality performance category. The Academy supports CMS’ belief that including additional administrative-claims based measures in the QPP will reduce the burden associated with quality reporting. We also support efforts to focus on population health and prevention measures for all MIPS eligible clinicians. As a step in this direction, CMS is proposing a new quality measure, “All-Cause Unplanned Admission for Patients with Multiple Chronic Conditions,” to be added for the 2023 MIPS payment year. The Academy supports the overall concept of quality outcome measures that help to drive cost-effective and appropriate care for Medicare patients with multiple chronic conditions. MNT provided by RDNs is a widely recognized component of medical guidelines for the prevention and treatment of most of the chronic conditions noted in the measure specification, including heart disease, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease. As previously noted, MNT provided by an RDN is linked to reduced hospital admissions for people with obesity, diabetes, and disorders of lipid metabolism, as well as other chronic diseases. The Academy agrees with CMS regarding the need for adequate time to work through operational factors of implementing the proposed measure and so support waiting until the 2021 reporting year to add the measure. We also seek clarification as to whether this measure would apply to all MIPS eligible clinicians or just physicians.

CMS is proposing the addition of a new specialty measure set for Nutrition/Dietitian. The Academy supports creation of this measure set as it provides an easy way for RDNs to know what quality measures are available for selection for reporting under the Quality performance category. In addition to the current quality measures available for RDNs, CMS is proposing to include in this specialty measure set the NCQA measure, “Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents.” The Academy supports inclusion of this measure in the specialty measure set as it may provide another potential measure for RDNs to report under Medicaid and All-Payer options.

CMS is proposing changes to the following quality measures as proposed by the respective measure stewards:

  • Diabetes: Hemoglobin A1c Poor Control (>9%)
  • Preventive Care and Screening: Body Mass Index Screening and Follow-up Plan

The Academy supports the proposals as we agree with the rationales provided.

Finally, the Academy urges CMS to adopt the following malnutrition electronic clinical quality measures (eCQMs) adopted by the National Quality Forum18:

  • NQF #3087/MUC16-294: Completion of a Malnutrition Screening within 24 hours of Admission
  • NQF #3088/MUC16-296: Completion of a Nutrition Assessment for Patients Identified as At-Risk for Malnutrition within 24 hours of a Malnutrition Screening
  • NQF #3089/MUC16-372: Nutrition Care Plan for Patients Identified as Malnourished after a Completed Nutrition Assessment
  • NQF #3090/MUC16-344: Appropriate Documentation of a Malnutrition Diagnosis

Through the QPP and other regulatory initiatives, CMS has already noted their intent to align quality measures across all care settings. Adoption of the malnutrition eCQMs provides an important opportunity to address malnutrition beyond the hospital and throughout the community at-large, as described in The National Blueprint: Achieving Quality Malnutrition Care for Older Adults,19 and to make sure care is delivered safely, effectively, equitably, and timely. To that end, the Academy has re-specified these four eCQMs for use in the outpatient setting and submitted them for potential use in the MIPS through a qualified clinical data registry for reporting by eligible clinicians in 2020. The Academy recommends CMS include these malnutrition measures for their relevance to nutritionally compromised patients in the outpatient setting.

Cost Performance Category
The Academy is pleased to see proposals to add 10 episode-based measures to the cost performance category starting with the 2020 MIPS performance period. The Academy has been participating in several of the clinical care subcommittees charged with developing new episode-based measures and looks forward to continued opportunities to do so in the future. The Academy urges CMS to continue to include the full range of provider types in the development of such measures to fully capture the total cost of care involved in these episodes of care.

The Academy also supports a gradual increase of the weighting of the cost performance category.

Improvement Activities Performance Category
CMS is proposing a new Improvement Activity (IA) for the MIPS CY 2020 performance period: IA_CC_XX Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes. CMS is proposing that clinicians who choose to report the modifiers on 50 percent or more of their Medicare claim for a minimum of a continuous 90-day period would earn one high-weighted improvement activity. The Academy supports the addition of this Improvement Activity to assist CMS in testing the reliability and validity of the modifiers in measuring the clinician's relationship to and responsibility for the Medicare patients before considering whether to require reporting of the modifiers in the future. We agree with weighting the activity as high due to the significant investment of time and resources required.

The Academy also recommends several other additions to the IA measure inventory. The Academy has completed work on Improvement Activity tools for use by RDNs. One such resource tool is the Standards of Excellence (SoE) Metric Tool. The SoE Metric Tool directly aligns with the IA component within the MIPS program. The MIPS IA component encourages providers to establish and conduct practice improvement activities best suited for their practice. The SoE Metric Tool is a self-assessment tool for RDNs to measure and evaluate their practice’s programs, services and initiatives that identify and distinguish the RDN brand as the professional expert in food and nutrition. RDNs utilizing this tool will be able to input pertinent data, identify gaps within performance, and ultimately generate quality improvement programs and activities. The Academy recommends CMS incorporate the SoE tool into the IA inventory and allow RDNs to report Improvement Activities through this tool when they become eligible clinicians under MIPS.

The Academy recommends CMS include in the IA Inventory under Population Management the integration of a registered dietitian onto the care team. This IA is evidence-based, aligns well with several of the existing activities under this domain, and is consistent with the existing recommendation to integrate a pharmacist into the care team to assist with medication management.

The Academy recommends development and inclusion of an IA measure on referrals to RDNs for MNT services for patients with nutrition-related chronic conditions (including chronic renal disease stage 3 and 4 and diabetes, for which Medicare Part B benefits exist and are underutilized) in accordance with clinical practice guidelines. MNT provided by RDNs for prevention, wellness and disease management improves patient health and increases productivity and satisfaction levels through decreased doctor visits, fewer hospitalizations and re-admissions, and reduced prescription drug use. RDNs' expertise and extensive training enable them to deliver coordinated, cost-effective care for a variety of chronic diseases, including obesity, hypertension, diabetes, disorders of lipid metabolism, HIV infection, unintended weight loss in older adults and chronic kidney disease.20 RDNs are recognized as the most qualified food and nutrition experts by the National Academy of Medicine (formerly IOM), most physicians, numerous clinical guidelines, and as evidenced by recommendations of the United States Preventive Services Task Force (USPSTF), providing nutrition care more effectively at a lower cost than physicians, nurse practitioners, and physician assistants. Given the lack of coverage for MNT services for all but a handful of disease states, it is not surprising that the service is underutilized when it might be more effective. To solve long-term problems in the Medicare program, we must aim for both earlier intervention and for prevention in cases where it is demonstrated to pay off. Nutrition-related chronic diseases and conditions, such as hypertension, obesity, and diabetes mellitus, are both costly and common in the United States. Nutrition management of multiple chronic conditions by improving overall nutrition intake is both cost-effective and an integral component of treatment. Given the low utilization of MNT when it could make a significant impact, CMS should develop process and outcome quality measures of appropriate use that recognize the benefits of referring patients to RDNs for MNT, consistent with the explicit recommendations of the USPSTF.

Finally, the Academy recommends inclusion of the Malnutrition Quality Improvement Initiative (MQii) Toolkit and accompanying composite measure under the Improvement Activity performance category. This resource could serve as an opportunity for practitioners in clinics to use the tools to implement care coordination and improve transitions of care across settings in their system.

The Malnutrition Quality Improvement Initiative (MQii) offers a paired set of quality improvement resources -- a quality improvement toolkit and the Global Malnutrition Composite Score (Composite Measure) -- to advance evidence-based, high-quality, patient-driven malnutrition care. The program consists of using an interdisciplinary toolkit to target areas of malnutrition quality improvement and accompanying composite measure to track and monitor improvement on four key steps of malnutrition care. These steps include screening patients for risk of malnutrition, performing a nutrition assessment for those found to be at-risk, and finally documenting a nutrition care plan as well as a medical diagnosis for patients found to be malnourished upon assessment.

The MQii Toolkit provides user guidance to identify, implement, and assess changes resulting from malnutrition quality improvement efforts for achieving optimal malnutrition care in their practice. It is targeted to patients ages 65+ but the information and resources in the Toolkit can be used for all adult patients. Similarly, the composite measure is designed for facility-level use for patients ages 65+ but can easily be adapted to clinician-level use. Clinicians can better coordinate care for malnourished patients as well as those at-risk by establishing a standardized process for identification, treatment and follow-up care. The standardized process supported by the Toolkit and composite measure use a model that involves an interdisciplinary care team to coordinate appropriate care and communicate patient needs based on level of risk and severity of malnutrition. The Toolkit and eCQMs are available at http://www.MQii.today.

Promoting Interoperability (PI) Performance Category
CMS is proposing to continue the existing policy of reweighting the Promoting Interoperability performance category for certain types of non-physician practitioner MIP eligible clinicians for the performance period in 2020, including registered dietitians or nutrition professionals. The Academy supports the continued exclusion as there currently are not sufficient measures applicable and available to RDNs under this performance category.

The Academy has ongoing efforts underway to support the development and testing of nutrition content as part of the HL7 FHIR specification which includes the NutritionOrder resource and mapping of Nutrition Care Process elements to the CarePlan resource. We participated in the HIMSS 2018 Interoperability Showcase and Public Health Informatics Conference connected demonstrations highlighting these capabilities for a dietitian referral scenario. While current CEHRT criteria related to promoting interoperability are based on exchange of C-CDA documents, as the FHIR standard and APIs evolve, this pathway may provide RDNs and other specialty providers more efficient ways to support electronic referral loops among MIPS eligible and non-MIPS providers. We encourage CMS to consider creating future interoperability measures that support the adoption of Application Programming Interfaces as alternative means of demonstrating performance in this category.

Public Reporting on Physician Compare
CMS is considering adding patient narratives to the Physician Compare website in future rulemaking based on requests from Medicare patients and caregivers for such information, similar to what they can find on other consumer-oriented websites. While purchasing health care services is not the same as purchasing consumer goods and merchandise on-line, the Academy recognizes we are living in a digital age where individuals are seeking such information and can already find it through other sources. The Academy recommends CMS proceed carefully down this path. In some situations, unbiased and validated information on how a Medicare patient experiences a provider may be of benefit. At the same time, providers may feel compelled to provide patients with what they "want" rather than what they "need" to avoid bad ratings that could negatively impact their practice. When a patient does not receive what they "want" (e.g., a prescription or test), it does not necessarily mean that they did not receive appropriate and quality care.

6. MIPS Value Pathways (MVPs)

The Academy appreciates the opportunity to provide input to CMS on their Request for Information on a new concept within the Quality Payment Program, namely applying a MIPS Value Pathways (MVP) framework to future proposals beginning with the 2021 MIPS performance period (2023 MIPS payment year). The intent behind the MVP is to simplify MIPS, improve value, reduce burden, help patients compare clinician performance, and better inform patient choice in selecting clinicians. The MVP framework would also provide enhanced data and feedback to clinicians. The MVP framework would connect measures and activities across the 4 MIPS performance categories, incorporate a set of administrative claims-based quality measures that focus on population health, provide data and feedback to clinicians, and enhance information provided to patients. The framework incorporates a foundation that leverages promoting interoperability measures. The MVP framework would move away from the fragmented reporting rules of the current MIPS program toward an approach focused on clinical episodes of care. CMS's goal is to eventually require all MIPS eligible clinician to participate through an MVP or a MIPS Advanced Payment Model (APM).

CMS proposes the following four guiding principles to define MVPs:

  1. MVPs should consist of limited sets of measures and activities that are meaningful to clinicians, which will reduce or eliminate clinician burden related to selection of measures and activities, simplify scoring, and lead to sufficient comparative data.
  2. MVPs should include measures and activities that would result in providing comparative performance data that is valuable to patients and caregivers in evaluating clinician performance and making choices about their care.
  3. MVPs should include measures that encourage performance improvements in high priority areas.
  4. MVPs should reduce barriers to APM participation by including measures that are part of APMs where feasible, and by linking cost and quality measurement.

The Academy appreciates CMS's recognition that the flexibility they have built into the Merit-based Incentive System (MIPS) has resulted in a complex program. ECs and other Medicare providers, such as RDNs, who elect to "opt in" to the MIPS have been challenged to master new terminology, performance measures, reporting standards and requirements along with in many cases implementing practice redesign. Eligible clinicians added in later years of the QPP have not been afforded the same "ramp up" period as the initial "class" of ECs, putting them at a potential disadvantage as performance category weights and performance thresholds become more challenging. Overall, the Academy supports modifications to the Quality Payment Program (QPP) that incentivize and enable the health care system to provide the right care at the right time. The Academy urges CMS to carefully consider how changes to the QPP can incentivize or preclude consumer (Medicare beneficiary and Medicaid enrollee) access to clinically effective services provided by non-physician Medicare providers.

The Academy supports the four proposed guiding principles for the MVPs. As CMS explores the MVP concept, the Academy is concerned that, like the overall design of the QPP, it is being done through the lens of physician-providers only. By using promoting interoperability measures as a foundation for the MVPs, it automatically excludes a large cadre of valuable Medicare providers, including RDNs, from participation in such pathways. In addition, the current cost measures are specifically targeted to physicians. If these physician-centric design elements are ultimately implemented, CMS may fall short of meeting its goal of requiring all MIPS eligible clinician to participate through an MVP or a MIPS Advanced Payment Model (APM). As a result, CMS may not be maximizing opportunities to fully transform the delivery and payment systems.

With these overarching thoughts in mind, the Academy offers the following input to help shape future proposals for MVPs:

  1. We support designing pathways around specialties/areas of practice as well as public health priorities. We believe both types of pathways are important to ensure at least one MVP is available for every type of eligible clinician. Pathways designed around public health priorities may further drive integrated team-based care across settings (i.e., health care facilities and community-based care). At the same time, as noted in our comment below (b), there are challenges in designing such pathways to support participation by all MIPS eligible clinicians. Designing pathways around specialties would help to overcome this concern.
  2. We support providing clinicians with a list of MVP options and/or measures and activities within a pathway from which to choose. The concept of designing MVPs around areas of practice appears at first glance to be a good option. However, as we review the example MVPs we are concerned that not all the proposed measures in the quality, cost and improvement activities are relevant to the range of providers who significantly contribute to the care of the targeted population (e.g., diabetes). Offering choice to clinicians may help to overcome this potential problem.
  3. To make promoting interoperability an achievable goal for all providers (physicians and non-physicians, large and small practices, urban and rural practices), the Academy encourages CMS to provide financial support (e.g., grants) and continued technical assistance to all provider types not previously included in the EHR Incentive Program to make access to health information technology a reality. Also, while current CEHRT criteria related to promoting interoperability are based on exchange of C-CDA documents, as the FHIR standard and APIs evolve, this pathway may provide RDNs and other specialty providers more efficient ways to support electronic referral loops among MIPS eligible and non-MIPS providers. We encourage CMS to consider creating future interoperability measures that support the adoption of Application Programming Interfaces as alternative means of demonstrating performance in this category.
  4. We are concerned that the proposed timeline for transitioning into MVPs may be overly aggressive considering the time and testing needed to develop valid and meaningful pathways that meet the needs of all ECs. We view the transition to MVPs as a major undertaking that requires careful consideration to reach its stated goal rather than creating further confusion and disruption for clinicians and patients.
  5. We recommend that CMS create subcommittees comprised of relevant stakeholders (clinicians and patients), similar to the process used for the MACRA episodes of care, to develop MVPs.
  6. The Academy recommends CMS include as a population health and prevention measure set assessment of nutrition status for early identification and treatment of malnutrition in all its forms (including both undernutrition and obesity). The electronic composite measure of optimal malnutrition care developed by the Academy and Avalere Health should serve as a foundational piece of this population health measure as well as the malnutrition eCQMs re-specified for use in the outpatient setting and submitted for potential use in the MIPS as noted above. Assessing nutrition status using validated tools in all settings across the continuum of health care is a vital first step in improving the health of Medicare beneficiaries, and our nation as a whole, as noted in The National Blueprint: Achieving Quality Malnutrition Care for Older Adults.22 Malnutrition is associated with many adverse outcomes.

    Beyond nutrition screening, it is imperative that patients identified at nutrition risk be referred to RDNs for a complete nutrition assessment and, as appropriate, development and implementation of an individualized plan of care aimed at improving nutrition status. Unfortunately, a disconnect often exists between screening for nutrition risk and appropriate referrals and follow-up. Far too often identification and treatment of malnutrition does not occur until a person gets admitted to a hospital.

    In short, older adults are a particularly vulnerable population for poor nutrition. They are at higher risk of malnutrition than other age groups and will therefore benefit substantially from improved malnutrition care. Chronic diseases such as cancer, stroke, diabetes, gastrointestinal, pulmonary, and heart disease and their treatments can result in changes in nutrient intake that can subsequently lead to malnutrition.23,23 The importance of malnutrition prevention and identification and intervention of at-risk and malnourished individuals is magnified by malnutrition's impact on independence, healthy aging, and the severity of medical conditions and disabilities.

    Two separate reports published by the AHRQ Hospital Cost Utilization Project (HCUP) clearly detail the burden of malnutrition on patients in the hospital setting and the significant increased costs of care.25,26 Overall, the economic burden of disease-associated malnutrition in the U.S. is estimated to be as high as $157 billion in 2014, with $51.3 billion associated with older adults.27 With the number of adults aged 65 years and older expected to reach 74 million by 2030, it is critical that CMS incorporate into the QPP the necessary performance measures to support early identification and treatment of this potentially costly condition in the non-institution setting to help improve patient outcomes and decrease health care spending.

As CMS considers further enhancements to the QPP, the Academy would like to bring to the agency's attention the fact that current regulatory limitations on the scope of the current Part B Medicare MNT benefit place severe limitations on Medicare beneficiary access to an efficacious and cost-effective service shown to improve both clinical and financial outcomes. If the Secretary would exercise her authority under Section 1834 (n) (42 USC 1395(m))28 of the Social Security Act to modify the current Part B Medicare MNT benefit to include diet-related chronic diseases experienced by Medicare beneficiaries, it would go a long way toward achieving CMS's goals of better care, smarter spending, and healthier people and to avoiding a migration of RDN providers out of the Medicare program. MNT provided by RDNs for prevention, wellness and disease management improves patient health and increases productivity and satisfaction levels through decreased doctor visits, fewer hospitalizations and re-admissions, and reduced prescription drug use. RDNs' expertise and extensive training enable them to deliver coordinated, cost-effective care for a variety of chronic diseases, including obesity, hypertension, diabetes, disorders of lipid metabolism, HIV infection, unintended weight loss in older adults and chronic kidney disease.29 RDNs are recognized as the most qualified food and nutrition experts by the National Academies of Sciences, Engineering and Medicine's Health and Medicine Division (formerly the IOM), most physicians, and the United States Preventive Services Task Force (USPSTF) for providing nutrition care more effectively at a lower cost than physicians, nurse practitioners, and physician assistants.30

The Academy reminds CMS of the National Academy of Medicine's recommendation that, "the Medicare program should support policies that would allow all qualified practitioners to practice to the full extent of their educational preparation."31 As CMS continues its efforts to achieve its goals of better care, smarter spending, and healthier people through the Quality Payment Program, it is important that it sets policies that fully leverage the contributions of all highly qualified members of the health care workforce, including both primary care and specialty care providers. The pool of RDN Medicare providers would grow, increasing access to clinically effective, low cost services that would be more appropriately incentivized through both pathways of the Quality Payment Program.

7. Analysis of the Fee Schedule Impact on Specialties

CMS routinely and inexplicably omits analysis of the impact of the proposed physician fee schedule changes for the RDN specialty; RDNs are not listed in Table 110 "CY 2020 PFS Estimated Impact on Total Allowed Charges by Specialty." CMS's omission of RDNs in Table 110 makes it difficult for the Academy and RDN Medicare providers to recognize the impact of fee schedule changes on their practices. The Academy urges CMS to annually include the RDN specialty in this table to facilitate an analysis of fee schedule changes on this vital healthcare specialty.

Thank you for your careful consideration of the Academy’s comments on the proposals for the 2020 Medicare Physician Fee Schedule and Quality Payment Program. Please do not hesitate to contact Jeanne Blankenship by phone at 312-899-1730 or by email at jblankenship@eatright.org or Marsha Schofield at 312-899-1762 or by email at mschofield@eatright.org with any questions or requests for additional information. The Academy looks forward to continued opportunities to work with CMS to design a health care delivery and payment system that improves the health of the nation and meets the needs of all stakeholders.

Sincerely,

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


1 The 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.

2 Medical 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 September 5, 2019.

3 Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Mental Health and Addictions Journal of the Academy of Nutrition and Dietetics, October 2018, Volume 118, Number 10.

4 Drug Overdose Response Investigation (DORI) Data Collections (Docket No. CDC-2017-0055). https://www.eatrightpro.org/news-center/on-the-pulse-of-public-policy/regulatory-comments/academy-comments-to-cdc-re-nutrition-interventions-and-drug-overdose-response-investigation-dori-data-collections. Accessed September 5, 2019.

5 Gawad, S.S.A.E., et al., Effects of drug addiction on antioxidant vitamins and nitric oxide levels. J. Basic Appl. Sci. Res., 2010. 1(6): p. 485-491.

6 Hossain, K.J., et al., Serum antioxidant micromineral (Cu, Zn, Fe) status of drug dependent subjects: Influence of illicit drugs and lifestyle. Subst Abuse Treat Prev Policy, 2007. 2: p. 12.

7 Mannan, S.J., et al., Investigation of serum trace element, malondialdehyde and immune status in drug abuser patients undergoing detoxification. Biol Trace Elem Res, 2011. 140(3): p. 272-83.

8 Santolaria-Fernandez, F.J., et al., Nutritional assessment of drug addicts. Drug Alcohol Depend, 1995. 38(1): p. 11-8.

9 Varela, P., et al., Human immunodeficiency virus infection and nutritional status in female drug addicts undergoing detoxification: anthropometric and immunologic assessments. Am J Clin Nutr, 1997. 191997(66): p. 504S-508S.

10 Islam, S.K.N., K.J. Hossain, and M. Ahsan, Serum vitamin E, C and A status of the drug addicts undergoing detoxification: influence of drug habit, sexual practice and lifestyle factors. European Journal of Clinical Nutrition, 2001. 55: p. 1022-1027.

11 Baptiste, F., Drugs and diet among women street sex workers and injection drugs user in Quebec City. Canadian Journal of Urban Research, 2009. 18(2): p. 78-95.

12 Saeland, M., et al., High sugar consumption and poor nutrient intake among drug addicts in Oslo, Norway. Br J Nutr, 2011. 105(4): p. 618-24.

13 Anema, A., et al., Hunger and associated harms among injection drug users in an urban Canadian setting. Substance Abuse Treatment, Prevention, and Policy, 2010. 5(20).

14 Nazrul Islam, S.K., et al., Nutritional status of drug addicts undergoing detoxification: prevalence of malnutrition and influence of illicit drugs and lifestyle. Br J Nutr, 2002. 88(5): p. 507-13.

15 Ross, L.J., et al., Prevalence of malnutrition and nutritional risk factors in patients undergoing alcohol and drug treatment. Nutrition, 2012. 28(7-8): p. 738-43.

16 Drug Overdose Response Investigation (DORI) Data Collections (Docket No. CDC-2017-0055). https://www.eatrightpro.org/news-center/on-the-pulse-of-public-policy/regulatory-comments/academy-comments-to-cdc-re-nutrition-interventions-and-drug-overdose-response-investigation-dori-data-collections. Accessed September 5, 2019.

17 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 2008. http://www.andevidencelibrary.com/mnt.

18 https://www.eatrightpro.org/practice/quality-management/quality-improvement/malnutrition-quality-improvement-initiative. Accessed September 5, 2019.

19 Defeat Malnutrition Today. Avalere Health and Malnutrition Quality Collaborative. The National Blueprint: Achieving Quality Malnutrition Care for Older Adults. Defeat Malnutrition Today. Published March 2017.

20 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Effectiveness Systematic Review 2009, 2013-2015. http://www.andeal.org/mnt

21 Committee on Nutrition Services for Medicare Beneficiaries. "The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population." Washington, DC: Food and Nutrition Board, Institute of Medicine; January 1, 2000 (published).

22 Defeat Malnutrition Today. Avalere Health and Malnutrition Quality Collaborative. The National Blueprint: Achieving Quality Malnutrition Care for Older Adults. Defeat Malnutrition Today. Published March 2017.

23 Agarwal E, Ferguson M, Banks M, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clin Nutr. 2013:32(5):737-745.

24 Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr. 2008;27(1):5-15.

25 Weiss AJ, Fingar KR, Barrett ML, et al. Characteristics of Hospital Stays Involving Malnutrition, 2013: Statistical Brief #210. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD) 2016.

26 Fingar KR, et al. Statistical Brief #281: All-Cause Readmissions Following Hospital Stays for Patients with Malnutrition, 2013. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project. September 2016.

27 Snider J, et al. Economic burden of community-based disease-associated malnutrition in the United States. JPEN J Parenteral Enteral Nutr. 2014;38:55-165.

28(n) AUTHORITY TO MODIFY OR ELIMINATE COVERAGE OF CERTAIN PREVENTIVE SERVICES FOR ELIGIBLE ADULTS IN MEDICARE.—Notwithstanding any other provision of this title, effective beginning on January 1, 2010, if the Secretary determines appropriate, the Secretary may—
(1) modify—
(A) the coverage of any preventive service described in subparagraph (A) of section 1861(ddd)(3) to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force; and the services included in the initial preventive physical examination described in subparagraph (B) of such section; and
(B) the services included in the initial preventive physical examination described in subparagraph (B) of such section; and
(2) provide that no payment shall be made under this title for a preventive service described in subparagraph (A) of such section that has not received a grade of A, B, C, or I by such Task Force.

29 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Effectiveness Systematic Review 2009, 2013-2015. http://www.andeal.org/mnt

30 Committee on Nutrition Services for Medicare Beneficiaries. "The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population." Washington, DC: Food and Nutrition Board, Institute of Medicine; January 1, 2000 (published).

31 IOM (Institute of Medicine). 2012. Geographic adjustment in Medicare payment: Phase II: Implications for access, quality, and efficiency. Washington, DC: The National Academies Press.