Academy Comments on the Health Care Payment Learning and Action Network’s (LAN) Primary Care Payment Models draft White Paper

November 18, 2016

William E. Golden, MD, MACP, Chair
Susan Edgman-Levitan, PA, Chair
Primary Care Payment Model Work Group
Health Care Payment Learning & Action Network

Re: Primary Care Payment Models Draft White Paper

Dear Dr. Golden, Ms Edgman Levitan, and Work Group members:

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on the Health Care Payment Learning and Action Network's (LAN) Primary Care Payment Models draft White Paper. The Academy of Nutrition & Dietetics is proud to support the adoption of Category 3 and 4 Alternative Payment Models as LAN Committed Partners. Representing more than 100,000 registered dietitian nutritionists (RDNs)1, nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation’s health through food and nutrition across the lifecycle. Every day we work with Americans in all walks of life — from prenatal care through end of life care — providing nutrition care services and conducting nutrition research. RDNs independently provide professional services such as medical nutrition therapy (MNT)2 under Medicare Part B.

The Academy supports the LAN's attention on primary care and its recognition of the need to articulate key principles and recommendations to ensure that primary care thrives in Alternative Payment Models (APMs). The Department of Health and Human Services' goals of Better Care, Smarter Spending, and Healthier People will only be realized if primary care practices and high value providers who deliver person-centered care have flexibility in how care is provided, high levels of professional satisfaction, the ability to engage consumers in their care, the right financial incentives, and fair compensation to retain and grow a skilled and engaged primary care workforce.

The Academy strongly supports the Principles and Recommendations in the PCPM because they collectively help establish a foundation from which stakeholders can build the infrastructure and create the right financial incentives for team-based, population-focused, person-centered care. There are numerous gaps in care associated with the fee-for-service model (e.g., MNT) and the Academy believes that the Principles and Recommendations of the PCPM will ultimately help stakeholders address critical gaps in care that will, over time, improve health outcomes and decrease the total cost of care.

There is a philosophy of team-based care put forth in the White Paper that practices must have the utmost flexibility to build teams that will address the needs of their populations. If payers embrace the PCPM, primary care practices should have the ability to bring on the experts and other personnel necessary to address the range of routine to complex needs and modifiable social determinants of health. There is widespread agreement that health risk behaviors – poor nutrition, excessive alcohol consumption, inactivity, tobacco use – are major contributors to the majority of illness, suffering, and premature death associated with chronic diseases and conditions and their associated health care costs.3 The Academy supports this philosophy of the model as it creates the possibility for the integration of nutrition care - and other important services - into primary care as a way to cost-effectively prevent and manage chronic disease, improve health outcomes, and decrease both the short-term and long-term total cost of care. Data show that Medical Nutrition Therapy (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.4 MNT provided by RDNs reduces A1c at all stages of the diabetes continuum of care.5,6 The Academy supports the philosophy and principles intended to create strong health care teams, and also recommends the following:

Consider removing the names of specific providers and personnel, or alternatively create a more comprehensive list of providers.

The draft White Paper specifically identifies nurse practitioners, physician assistants, pharmacists, behavioral therapists, social workers, community health workers and administrative personnel as examples of a more varied set of health professionals.7 The White Paper also identifies community health workers and health coaches as emerging professionals in the composition of primary care teams.8 While it is clear that the intent of the PCPM is to enable provider organizations and practices to cast a wide net when selecting the right expertise and personnel for primary care teams, the act of naming specific providers may have the unintended consequences of limiting others. If the work group concludes that listing specific examples of providers will ultimately be helpful to provider organizations and practices as they consider a broad range of providers, then the Academy recommends that the PCPM include a broader list of other providers that includes RDNs. If the work group requires substantiation for including RDNs in a more comprehensive list of providers, that information is provided below.

RDNs will help teams address goals of primary care
Inclusion of the RDNs in the "menu" of possible providers for primary care teams is in alignment with the White Paper emphasis on "the need for primary care teams to focus on health promotion and maintenance, preventive services, engagement and education for patients and families; care planning and care coordination across multiple care delivery settings."9 Registered Dietitian Nutritionists are not only cost-effective providers of Medical Nutrition Therapy, but possess competencies in other areas including case management and care coordination, self-management, smoking cessation, and lifestyle interventions.

Improve Obesity Treatment in Primary Care
Nationally, thirty eight percent of adults have obesity according to the most recent State of Obesity report.10 In the most recent obesity treatment guidelines, the studies that formed the evidence base (Strong, Grade A) for the recommendation to refer to a nutrition professional for counseling, registered dietitians usually delivered the dietary guidance (Recommendation component of 3b).11 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."12 Additionally, RDNs can provide Medicare's Intensive Behavioral Therapy for Obesity (IBT). RDNs are considered auxiliary personnel and can furnish this benefit under the conditions specified in regulations at 42 CFR Section 410.26(b).13

Important Providers in Diabetes Care
In addition to providing MNT for diabetes, the National Standards of Diabetes Self-Management Education and Support require at least one of the instructors responsible for designing and planning Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS) will be a registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a Certified Diabetes Educator or Board Certified-Advanced Diabetes Management.14

Profession of LAN Committed Partners
The Academy, on behalf of its members, is committed to accelerating the adoption of Alternative Payment Models, especially APMs in Category 3 and 4 because of their potential to drive improvements in health care delivery, improve the health of populations, and reduce per capita cost. The Academy is preparing its members to contribute as high value and accountable providers in various areas of care, and especially in primary care.

Consider a statement about establishing stakeholder standards for shared data
In addition to the Principles and Recommendations that provide a solid foundation for team based care, the Principles and Recommendations correctly identify the required "infrastructure" for making population-based care and payment possible: Recommendation 17: PCPCMs should foster data sharing and analysis to facilitate care coordination, patient engagement, population health management, and performance assessment. The Recommendation identifies the need for payers to share aggregate, multi-payer data on plan and practice performance on cost and quality metrics. The suggestion that an infrastructure is needed to allow patient level-data to follow the patient would certainly assist primary care teams at the point of care and in population based strategies. It may be helpful for the LAN to recommend that stakeholders work to standardize the type or minimum amount of data that must be shared. The transfer of risk-adjusted data used to form the basis for prospective population based payments is critical for primary care practices to receive adequate payments.

Stronger statements about transfer of risk-adjusted data from payer to payer
The data sharing recommendations do not adequately address when data about patient risk/acuity should be transferred from one payer to another when consumers change payers. The unintended consequences of slow or incomplete transfer of accurate risk adjusted data from one payer to another could be reduced payments to primary care practices. If risk-adjusted prospective payments for primary care are the goal, the LAN may want to consider stronger statements about the timely transfer of data between payers to facilitate appropriate risk adjusted prospective or retrospective payments to practices that enable greater financial predictability and stability for practices.

Define the practice threshold for assuming risk
The White Paper emphasizes that patient panel size is an important factor in determining the level of downside risk provider organizations and practices can reasonably assume. All stakeholders are likely to benefit from the inclusion of more specific information as to what constitutes small, medium and large panel size, in addition to the other critical factors when assessing the ability to assume downside risk.

Lastly, the Academy has one final recommendation for the LAN that falls outside of the goals of this White Paper.

Consider developing related resources to help stakeholders facilitate the payment of frontline practitioners in alignment with the PCPM Principles and Recommendations.

The Academy acknowledges the White Paper focus is on the transfer of payment from payers to provider organizations or practices. The White Paper also emphasizes that frontline providers should receive payments that mirror the Principles and Recommendations of the PCPM. "In order to enable frontline practitioners to implement delivery reforms, and properly hold them accountable for managing costs and population health, these practitioners must receive payments that support the infrastructure needed for coordination and payment engagement."15 In the context of population based payments, provider organizations and practices assume the role of "payer" for other practitioners. The flow of funds in primary care will influence the creation and viability of primary care teams. The Academy recognizes the difficulty of providing specific instructions for operationalizing such payments to other frontline providers, and would like to see the LAN develop additional resources to help primary care practices in this endeavor. There may be unintended consequences of not providing guidance on how to pay frontline providers, including low confidence in the ability to create and afford the right cohesive inter-professional teams needed to improve outcomes. Figuring out how to pay frontline health care providers in alignment with the Principles of the PCPM could emerge as a significant challenge and barrier for practices. The LAN could play an important role in helping provider organizations and practices be successful in this endeavor, which will strongly influence the ability of practices to achieve the goals of improving care delivery and health outcomes. The Academy would be happy to be a part of any stakeholder efforts to create additional resources in this area.

The Academy strongly supports the Principles and Recommendations and hopes that the White Paper will play a pivotal role in launching the nation’s efforts to reconstruct and leverage the capabilities of strong primary care through the use of APMs. Thank you for the opportunity to review the White Paper and to provide input intended to strengthen the document so that it will be used by stakeholders across the county. We appreciate the care and rigor the Work Group put forth in developing the recommendations of the PCPM and look forward to reviewing and promoting the final product among our members. The Academy is available to be a resource for the LAN and this particular Work Group.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President, Policy & 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 July 2016. Accessed August 8, 2016.] The Academy’s definition of medical nutrition therapy is broader than the MNT definition established by Medicare Part B and other health plans. In addition, the Academy definition may differ from the MNT definition included in state licensure laws. The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans.

3 The Centers for Disease Control and Prevention. Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/chronicdisease/overview/. Accessed November 15, 2016

4 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 20013-15. http://www.andevidencelibrary.com/mnt. Accessed July 26, 2016

5 UK 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.

6 Coppell/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.

7 Ibid p.5

8 Ibid p.12

9 The Primary Care Payment Model Work Group, “Primary Care Payment Models Draft White Paper” 10/19/2016 page 5.

10 The Trust for America’s Heath and the Robert Wood Johnson Foundation, The State of Obesity: Better Policies for a Healthier America 2016. http://stateofobesity.org/fastfacts/

11 Jensen, et al “2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society,” Circulation. 2014;129[suppl 2]:S102-S138.

12 Committee 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.

13 Intensive Behavioral Therapy (IBT) for Obesity https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7641.pdf accessed August 4, 2016

14 Haas, et al “National Standards for Diabetes Self-Management Education and Support” Diabetes Care 2013 Jan; 36(Supplement 1): S100-S108 http://care.diabetesjournals.org/content/36/Supplement_1/S100.full accessed August 8, 2016.