Academy Comments to CMS re Medicare Merit-Based Incentive Payment System and Accountable Payment Models

November 17, 2015

Andrew M. Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: CMS-3321-NC2
P.O. Box 8016
Baltimore, MD 21244-8016

Re: Medicare Program; Request for Information Regarding Implementation of the Merit Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models (CMS-3321-NC2)

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on the Centers for Medicare and Medicaid Services (CMS) Request for Information Regarding Implementation of the Merit Based Incentive Payment System and Promotion of Alternative Payment Models (CMS-3321-NC2) published in the October 1, 2015 Federal Register. The Academy has over 75,000 members, including Registered Dietitian Nutritionists1 (RDNs), who independently provide professional services, such as medical nutrition therapy (MNT), under Medicare Part B.

The Academy supports CMS's continued efforts aimed at achieving Better Care, Smarter Spending, and Healthier People. MNT provided by RDNs is a widely recognized component of medical guidelines for the prevention and treatment of heart disease, diabetes, renal disease, obesity, and many other chronic diseases and conditions as well as in the reduction of risk factors for these conditions. As primary prevention, strong evidence supports optimal nutritional status as a cost-effective cornerstone in the maintenance of health, well-being, and functionality. As secondary and tertiary prevention, MNT is a cost-effective disease management strategy that reduces chronic disease risk, delays disease progression, enhances the efficacy of medical/surgical treatment, reduces medication use, and improves patient outcomes including quality of life.2 As such, MNT provided by RDNs can and should be an important component of any alternative health care delivery model and appropriately recognized in any new pay-for value payment systems. RDNs participate in the current Medicare Part B Physician Quality Reporting System, providing high quality, evidence-based care to patients and delivering substantial cost-savings to the health care system as a whole.

The Academy offers specific comment on the following priority areas identified in the October 20, 2015 notice of the extension of the comment period:

Subsection A: The Merit-Based Incentive Program System (MIPS)

  1. General Comments
  2. MIPS EP Identifier and Exclusions
  3. Quality Performance Category
  4. Clinical Practice Improvement Activities Category
  5. Development of Performance Standards
  6. Flexibility in Weighting Performance Categories

Subsection B: Alternative Payment Models (APMs)

A. The Merit Based Incentive Program System

1. General Comments

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) sets health care payments to physicians and non-physician Medicare providers on a new course. The goals set forth under MACRA are lofty, envisioning a perfect world of health care delivery and patient engagement. As CMS maps-out both MIPS and the Physician-Focused Payment Models (PFPMs), the Academy strongly urges CMS to consider and include provisions related to the needs of non-physician providers. Based on 2013 data, approximately 17% of eligible professionals ("EPs") for the Physician Quality Reporting System (PQRS) are "other healthcare professionals" (i.e., not an MD, DO, NP, PA, or CRNA).3 These "other healthcare professionals" — many of whom are independently reimbursable providers — render critical services to Medicare beneficiaries that improve health outcomes, enhance patient satisfaction, and control spending. As vital components of Medicare's healthcare delivery system, these highly qualified providers deserve the opportunity to earn incentive payments in a manner that recognizes unique differences in practice and available quality reporting measures that create a fair and equitable merit-based incentive system. If the MIPS is designed in a manner that does not meet these providers' needs, the Medicare program will disincentivize these providers from participating in the system, thereby creating access to care problems for beneficiaries. Given ongoing concerns over provider shortages, it is prudent to retain as many high performing professionals as possible within the Medicare program to effectively address the health needs of the Medicare population. The Academy recommends that CMS convene a Technical Expert Panel (TEP) comprised of individuals representing these "other professionals" to inform CMS's development of the MIPS to meet these critical needs. Representatives from the AMC RUC HCPAC could serve as members of such a TEP, as they are knowledgeable about the PFS, PQRS, and alternate payment models.

RDNs are eager to be part of a value-based payment system in which they are held accountable for the outcomes of their effective services. A number of RDNs are already participating in alternative payment models as part of forward-thinking physician office practices or through various Innovation Center initiatives (e.g., the Comprehensive Primary Care initiative and the Oncology Care Model). However, we note it is still the exception for physician office practices to directly employ and/or contract with RDNs as a result of the lack of explicit recognition by CMS and other payers of the value of RDNs as an essential part of the patient-centered health care team. Unfortunately, the traditional fee-for-service payment system simply has not adequately recognized the value of MNT services provided by RDNs, despite compelling evidence and national clinical practice guidelines explicitly supporting their contributions to the Triple Aim. As a result, access to vital MNT services only happens under a system heavily reliant upon referrals to RDNs who work in their own non-physician practice settings. In order to achieve CMS's ideal health care delivery and patient engagement system envisioned under MACRA, the following are required to effectively design the MIPS and other APMs:

  1. Physicians should either be mandated or incentivized to utilize nonphysician providers such as RDNs.
  2. Non-physician providers, such as RDNs, must be afforded the same opportunities to earn value-based payments as physicians and other Medicare providers, given RDNs' contribution to Better Care, Smarter Spending, and Healthier People.
  3. Non-physician providers, such as RDNs, should not be financially penalized for the MIPS and APMs not recognizing them. The systems must provide equitable opportunities (meaning equitable to physicians) for nonphysician providers to earn value based payments.

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 usage. RDNs' expertise and extensive training enable them to deliver coordinated, costeffective 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.4 RDNs are recognized as the most qualified food and nutrition experts, by the Institute of Medicine (IOM), most physicians, and the United States Preventive Services Task Force (USPSTF), providing nutrition care more effectively at a lower cost than physicians, nurse practitioners, and physician assistants.5

The Academy urges CMS to design accountable payment models supporting the IOM'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."6 As CMS continues its efforts to achieve its goals of Better Care, Smarter Spending, and Healthier People, it is important that it sets policies to fully leverage the contributions of all highly qualified members of the health care workforce, including both primary care and specialty care providers.

2. MIPS EP Identifier and Exclusions

As CMS considers how to best identify EPs to participate in MIPS, the Academy recommends using a Taxpayer Identification Number (TIN)/National Provider Identifier (NPI) combination, similar to what is currently done with the PQRS. This methodology not only appears to be working well but also adequately addresses EPs who provide services as both an individual provider as well as part of one or more group practices. Creating a unique MIPS identifier would add an unnecessary administrative burden to all parties (i.e., providers, group practices, and CMS) as systems would need to be established to apply for, create and update such identifiers. Quality and cost metrics could be attributed to each TIN/NPI combination with performance and payments calculated accordingly.

3. Quality Performance Category

The Academy recommends that CMS retain all current PQRS reporting mechanisms under the MIPS. In terms of reporting criteria under MIPS, the Academy urges CMS to consider an alternate, lower reporting requirement for highly specialized Medicare providers providing a limited scope of services with concomitantly limited applicable measures on which to report. As has been brought to CMS's attention in the past by many provider types, the current PQRS requirement to report at least nine measures is simply impossible for many EPs to meet, thus creating an administrative burden for CMS as it applies the MAV process. In addition, the current set of quality measures does not create equitable opportunities across all provider types to support a payment system that places more weight on outcomes measures. Until such time, the Academy supports efforts by CMS and other organizations to create more outcomes-based measures to support such a system in the future.

As noted in our comments to CMS on the CY2016 Physician Fee Schedule proposed rules, the Academy has concerns about the reporting of quality data stratified by race, ethnicity, sex, primary language and disability status. While we support efforts to reduce health disparities, we note that the collection of race information in particular poses unique challenges in that it is important to consider who will determine the categories used and who will select the category for a specific Medicare beneficiary. Specifically, we query whether the provider will be asked to select the category or will the patient self-report? Oftentimes assumptions about race may be made by the provider. Sufficient numbers of categories must exist to more accurately reflect the race of patients. The current Black, non-Hispanic White, Hispanic, Asian, and Other categories currently in use do not provide enough differentiation for evaluators of the data. Therefore, the Academy recommends that CMS work with the National Institute on Minority and Health Disparities and the HHS Office of Minority Health to determine appropriate race categories.

The Academy also recommends CMS consider collecting this data at the agency, rather than at the individual provider, level. Most of these items are constants and could be collected on each beneficiary as part of the Medicare application process, although we note that the one exception may be disability status as it may change over time. By capturing these data elements with eligibility information, it not only minimizes burden on providers but also ensures consistent and accurate data on each beneficiary. Alternately, CMS could establish an automated prompt to collect the data elements via claims systems. The request for the demographic information could be submitted to the eligible treating provider types who have submitted the most claims for individual patients within a certain time period. Once the demographic information is received by CMS, the request for information would be turned off. Such a system would prevent the need for multiple treating providers to be collecting and reporting the same information on the same patients. CMS could then leverage technology to analyze quality data stratified by each of these factors.

4. Clinical Practice Improvement Activities Category

In terms of activities that could be classified as clinical practice improvement activities, the Academy urges CMS to consider menus of options based on provider type, or in the alternative, be sure to incorporate activities that provide options meeting the needs of physicians, non-physicians, and other qualified health care professionals. Specifically, the Academy recommends CMS consider including the ability to provide same day appointments with RDNs and physicians (primary and specialty) to better meet patient needs and enhance access to care; provide expanded access through walk in appointments; support care coordination via telehealth; enhance beneficiary engagement through self-management training services; and enhance beneficiary engagement through patient self-assessment tools such as checklists, Apps (e.g., a sodium counter), or "Healthy Plate" evaluation tools.

CMS proposes a subcategory of Social and Community Involvement that might include measuring the number of completed referrals to community and social services. If such a measure is developed, the Academy recommends that a "completed referral" be defined as a referral that is made and acted upon. While we recognize many factors influence whether a referral is actually acted upon, defining "completed referrals" in this manner would require referring providers to close the loop on the referral process and move the system closer to an outcomes-based one. Finally, the Academy recommends that CMS either broaden this subcategory or create a new one to capture referrals to other providers such as RDNs within the medical neighborhood. These referrals are consistent with clinical practice guidelines and have been shown to improve health outcomes, enhance patient satisfaction, and control costs.

As CMS considers adding specific subcategories to the list of clinical practice improvement activities, the Academy urges CMS to carefully consider the burden on practices to report such activities and also consider whether or not payment should truly hinge on completion of such activities. For example, while health care providers appropriately participate in emergency preparedness and response activities, the Academy does not believe payment should be tied to such participation as many factors influence an individual EPs ability to do so.

When it comes to mechanisms for reporting clinical practice improvement activities, the Academy supports annual self-attestation directly to CMS. Qualified registries, QCDRs, EHRs or other health IT systems are not designed to capture and report on this type of data, nor should they be expected to be redesigned to do so. CMS could then utilize the RACs to randomly audit a subset of providers to verify the quality and accuracy of the reported data.

5. Development of Performance Standards

As the MIPS is developed, the Academy encourages CMS to ensure that it designs a system that does not only reward continuing improvement. As practices become high performers, their margin for continued improvement diminishes, but their contributions to quality, cost-effective care are still worthy of recognition and incentivizing. One of the flaws of some of the Medicare ACO models is that high performers had to pay money back to CMS even though they had high Star ratings. As a result, some of these high-performing organizations stopped participating in these programs. Maintaining a high level of performance should be rewarded in addition to rewarding new improvements in performance.

The Academy also recommends CMS consider improvement at the composite performance score level rather than at the measure level or performance category level. As performance is analyzed at a more granular level, the amount of data needed to produce valid and reliable measures increases and therefore may not be realistic or attainable for a solo EP or small practice to report.

6. Flexibility in Weighting Performance Categories

The Academy is pleased to note that MACRA requires the Secretary (if there are not sufficient measures and activities applicable and available to each type of EP) to assign different scoring weights (including a weight of zero) from those that apply generally under the MIPS. The Academy recommends that CMS make determinations at the specialty level when weighting of the performance categories, because we believe situations will vary based on the provider type, particularly when it comes to non-physician health care providers such as RDNs. Once again, CMS would benefit from Technical Expert Panels in designing this aspect of the MIPS.

B. Alternative Payment Models

As noted above, the Academy's fundamental concern is the need for CMS to consider the needs of non-physician providers as it promotes alternative payment models (APMs) and incentivizes participation in such models. Currently it is difficult for non-physician providers such as RDNs to participate in the existing APMs as they are only able to do so if a forward-thinking physician or ACO integrates an RDN into their organization. In most cases the RDN is part of a "virtual" Patient Centered Medical Home rather than being employed by the entity. In addition, APMs tend to require the use of certified Electronic Health Records technology, yet RDNs and other non-physician providers are not eligible to receive incentive payments to assist them in adopting such technology. Once again, the Academy recommends CMS convene a Technical Expert Panel comprised of individuals representing these "other healthcare professionals" to enable it to effectively develop incentive payments for participation in APMs. Representatives from the AMC RUC HCPAC could serve as members of such a TEP as they are knowledgeable about the PFS, PQRS, and alternate payment models.

The Academy is currently developing some alternate payment models for nutrition services, and we welcome the opportunity to share our work with CMS in the hopes that the agency would adopt the models and/or use them to inform their work around promoting and incentivizing APMs.

Thank you for your careful consideration of the Academy's comments on this request for information. We appreciate the agency extending the comment period to allow us time to more fully develop our response. Please do not hesitate to contact Jeanne Blankenship by phone at 202/775-8277, ext. 6004 or by email at or Marsha Schofield at 312/899-4787 or by email at with any questions or requests for additional information.


Jeanne Blankenship, MS, RDN
Vice President, Policy & Advocacy
Academy of Nutrition and Dietetics

Marsha Schofield, MS, RD, LD, FAND
Director, Nutrition Services Coverage
Academy of Nutrition and Dietetics

1 The Academy recently 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 Grade 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.'"

3 2013 Reporting Experience Including Trends (2007-2014), Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program. April 8, 2015. Centers for Medicare & Medicaid Services.

4 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 2008.

5 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).

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