Academy Comments to CMS re Medicare Physician Fee Schedule for CY 2016

September 8, 2015

Andrew M. Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: CMS-1631-P
P.O. Box 8013
Baltimore, MD 21244-8013

Re: File Code-CMS-1631-P; Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016; Proposed Rule; (July 15, 2015).

Dear Acting Administrator Slavitt:

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on CMS-1631-P Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016 published in the July 15, 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.

Overall, the Academy supports 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 RDNs participate in the 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 proposed rule items:

  1. Determination of Practice Expense (PE) Relative Value Units (RVUs)
  2. Determination of Malpractice (MP) Relative Value Units
  3. Improving Payment Accuracy for Primary Care and Care Management Services
  4. Medicare Telehealth Services
  5. Incident to Proposals: Billing Physician as the Supervising Physician and Ancillary Personnel Requirements
  6. Physician Compare website
  7. Physician Quality Reporting System (PQRS)
  8. Potential Expansion of the Comprehensive Primary Care (CPC) Initiative
  9. Value-Based Payment Modifier
  10. The Merit-based Incentive Payment System (MIPS)
  11. Analysis of the Fee Schedule Impact on Specialties

1. Determination of Practice Expense (PE) Relative Value Units (RVUs)

CMS proposes to use an average of the three most recent years of available Medicare claims data to determine the specialty mix assigned to each CPT code to determine the relative value units for Practice Expenses (PE). The Academy supports this change in methodology as we agree with the agency that it would increase stability of RVUs for PE.

2. Determination of Malpractice (MP) Relative Value Units (RVUs)

CMS proposes to begin conducting annual MP RVU updates to reflect changes in the mix of practitioners providing services. Using methodology similar to that proposed for determining PE RVUs, CMS proposes using an average of the three most recent years of available Medicare claims data to determine the specialty mix assigned to each CPT code to determine the relative value units for Malpractice (MP). In addition, CMS proposes a refinement in Step One of the MP RVU calculation that entails looking at local malpractice premium data for all persons in the population, not just those associated with Medicare patients, and calculating a weighted average of the local premiums to determine national premiums for each specialty. The Academy supports these changes in methodology as we agree with the agency that it would increase stability of RVUs for MP and does a better job of capturing the role of each local area's premium in the "national" premium for each specialty.

3. Improving Payment Accuracy for Primary Care and Care Management Services

CMS is looking at ways to better describe and value the physician work (time and intensity) specific to primary care and other cognitive specialties in the context of complex care of patients relative to the time and intensity of the procedure-oriented care physicians and practitioners, who use the same codes to report Evaluation/Management (E/M) services. The agency seeks comments on ways to recognize the different resources (particularly in cognitive work) involved in delivering broad-based, ongoing treatment, beyond those resources already incorporated in the E/M codes. As CMS notes, this work might involve medication reconciliation, the assessment and integration of numerous data points, effective coordination of care among multiple other clinicians, collaboration with team members, continuous development and modification of care plans, patient or caregiver education, and the communication of test results. CMS would require that the patient have an established relationship with the billing professional; and additionally, the use of an add-on code would require the extended professional resources to be reported with another separately payable service. However, in contrast to the Chronic Care Management (CCM) code, the new codes might be reported based on the resources involved in professional work, instead of the resource costs in terms of clinical staff time. The resource costs of this work may include the time and intensity related to the management of both long-term and, in some cases, episodic conditions. CMS is interested in stakeholder comments on the kinds of services that involve the type of cognitive work described above and whether or not the creation of particular codes might improve the accuracy of the relative values used for such services on the PFS.

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. Person-centered care provided by an interdisciplinary team of qualified health care professionals specific to the person's needs and coordinated by a primary care provider helps to achieve these goals. As CMS explores additional avenues to recognize such work through appropriate payment mechanisms, the Academy urges CMS to think beyond the role of the primary care providers and explicitly recognize the wide range of qualified non-physician practitioners located within or outside of a primary care provider’s office setting who effectively provide care management services. These non-physician team members are critical to achieving successful patient and population health outcomes and controlling the progression of chronic and complex chronic disease. Thus, there needs to be a payment mechanism for these essential services that is not exclusively tied to the primary care provider.

Over ⅔ of Medicare beneficiaries have two or more chronic conditions, and 14 percent have six or more chronic conditions. As noted in CMS' "Chronic Conditions among Medicare Beneficiaries 2012 Chartbook," more than half of Medicare beneficiaries have one or more chronic conditions, such as diabetes, hypertension, high blood cholesterol, heart disease and kidney disease.3 RDNs training and qualifications enable them to provide effective care management, particularly for patients with complex health needs. 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.4

The current MNT CPT codes used by RDNs to bill for the Medicare Part B MNT benefit do not adequately capture the additional professional resources necessary to provide care management services to Medicare beneficiaries with such complex needs to assist them in selecting and accessing adequate foods/nutrient sources, and/or understanding how their food selections impact their disease state and/or overall health. Both diabetes and chronic kidney disease are long-term conditions requiring ongoing MNT services to address food and nutrition needs over both a beneficiary’s lifetime as well as during episodic conditions, such as a stroke or hospitalization. RDNs provide critical care management services to ensure adequate access to healthful foods/nutrients, appropriate access to and use of medication, and to refer and facilitate access to appropriate health care and/or community-based resources (e.g., facilitating post-discharge nutrition care plans with post-acute care providers and community agencies such as Meals on Wheels). Such activities are time consuming but serve a necessary role in supporting patients' self-management of their chronic conditions. All experience challenges in everyday life related to their food choices and eating behaviors. RDN provided care management services provide consistent support rather than forcing the patient to wait for the next appointment with the RDN. Care management interactions often lead to modifications to a patient's goals and/or plan of care that require additional documentation in the patient's medical record. While RDNs may be considered "clinical staff" and so CMS may consider their time spent in care coordination activities as already being captured under the existing Chronic Care Management (CCM) code, RDNs and other qualified health care professionals who already have the statutory authority to bill CMS for services do not currently have a mechanism for being paid for this important additional professional work.

Thus, the Academy urges CMS to create an add-on code that could be used by non-physician Medicare providers similar to the CCM code to capture care coordination services provided to Medicare beneficiaries with complex medical needs. Criteria for use of this code might include presence of 2 or more chronic conditions, professional time in excess of 30 minutes per one calendar month for team communication and coordination of care for services identified as part of the treatment plan beyond the time already captured in the relevant "office visit" CPT code (e.g., 97802-4 for RDNs) for beneficiaries with whom the non-physician provider has an existing relationship as evidenced by billing for services during the calendar year. Such care coordination could occur between a non-physician qualified health care professional and a physician (primary or specialist), between non-physician qualified health care professionals or between non-physician qualified health care professionals and community-based services.

The Academy also urges CMS to recognize and implement separate payment beginning January 1, 2016 for other services utilized to improve care coordination and care collaboration that have already been defined by the CPT Editorial Panel and valued by the RUC. These services include:

  • Anticoagulant Management (CPT Codes 99363 and 99364)
  • Education and Training for Patient Self-Management (CPT Codes 98960-98962)
  • Medical Team Conference (CPT Codes 99366-99368)
  • Telephone Services (CPT Codes 99441-99443 and 98966-98969)
  • Analysis of Computer Transmitted Data (CPT Code 99091)
  • Complex Chronic Care Management Services (CPT Codes 99487 and 99489)

Payment for these services either does not currently exist under the PFS or is bundled under an E/M service, precluding access by non-physician members of the health care team who cannot bill using E/M codes. For example, while physician time spent in a medical team conference is recognized as part of an E/M service, non-physicians, such as RDNs and physical and occupational therapists, are not allowed to separately report the time that they spend in such conferences, whether the patient is present (CPT 99366) or not (CPT 99368). All of these services are clearly separate and distinct from E/M services.

RDNs, based on their education and training, are qualified to provide all of these services and often do so as part of team based care. For example, many RDNs train patients with diabetes on the use of continuous glucose monitoring devices and assist the physician in the analysis of data transmitted from such devices. RDNs within primary care provider practices play a role in managing patients on anticoagulant therapy per established protocols because of their in-depth knowledge of drug-nutrient interactions.5 Other payers already recognize the value of the above services in improving patient care and managing health care costs. Recognition of all of the above services within the Medicare program is important in capturing real costs to both physician and non-physician practices.

Immediate implementation of the anticoagulant management (CPT codes 99363-99364), education and training for patient self-management (CPT codes 98960-98962), medical team conferences (CPT codes 99366-99368), telephone services (CPT codes 98966-98969), analysis of computer transmitted data (CPT code 99091) and complex chronic care management services (CPT codes 99487-99489) is recommended to recognize the costs associated with team based care.

CMS is also seeking comment on how Medicare might accurately account for the resource costs of a more robust inter-professional consultation within the current structure of PFS payment. Medicare does not currently pay for CPT codes 99446-99449 as they consider such services as already part of other services provided to beneficiaries and paid for by Medicare. The Academy recommends that CMS begin separate payment for such inter-professional consultation services provided by physicians or other Medicare providers utilizing the existing CPT codes 99446-99499. Physicians and other qualified health care professionals rely on the expertise of their professional colleagues to assist in the diagnosis and/or management of complex patients. Under certain circumstances such consultation can appropriately be provided without the consultant qualified health care professional providing a face-to-face service to the patient, thus supporting the delivery of timely, cost-effective care. For example, for patients receiving enteral or parenteral nutrition, an RDN can assist the treating physician with making appropriate changes to the feeding regimen to address intolerance issues based on a review of the patient's medical record (laboratory results, medications, physical examination and review of systems documented by the physician) and conversation with the physician via telephone or internet. We do agree with CMS that appropriate beneficiary protections need to be in place, such as patient advanced consent to the consultation. Any consultative services delivered via the Internet should be performed in a HIPAA-compliant manner. It is important that such services not take the place of face-to-face or telehealth encounters when indicated as a component of evidence-informed practice. The Academy does not believe it is necessary for CMS to differentiate between such services and other PFS payments as these CPT codes have already factored such a need into account in their development so they should be implemented in accordance with existing CPT guidelines. Payment for such services should be tied to a beneficiary encounter by the patient's treating physician or other qualified health care professional as defined under section 1861 (s) of the Social Security Act [42 U.S.C. 1395x] (within seven days) to ensure documentation of a current physical examination.

The Academy also urges CMS to recognize obesity as a chronic condition for the purposes of all care coordination services. Obesity is an astronomically expensive problem for our nation and families. Medicare and Medicaid patients with obesity cost $61.8 billion per year.6 As such, CMS should recognize obesity as one of the chronic conditions that qualifies beneficiaries for any and all care coordination services. In June 2013, the American Medical Association's House of Delegates voted to recognize obesity as a disease. Over the last 20 years, obesity rates have doubled among adults, resulting in more than 35 percent of adults living with obesity and an additional 33 percent being overweight.7 Evidence suggests that without concerted action, roughly half the adult population will have obesity by 2040. These numbers are particularly troubling because one out of every eight deaths in America is caused by an illness directly related to obesity; therefore, millions of Americans are at risk from this preventable and treatable disease.8 Research studies document the harmful health effects of excess body weight, which increases the risk for conditions such as diabetes, hypertension, heart failure, dyslipidemia, sleep apnea, hip and knee arthritis, multiple cancers, renal and liver disease, musculoskeletal disease, asthma, infertility and depression.

4. Medicare Telehealth Services for the Physician Fee Schedule

CMS proposes to add HCPCS codes 90963-90966 to the list of telehealth services for CY 2016. RDNs within renal dialysis centers frequently provide such services. Adding these codes to the list of telehealth services expands beneficiaries' access to these services that are an important component of their care. Transportation to health care providers is often a challenge for this population and the use of telehealth technologies provides a convenient and cost-effective solution to this problem. In addition, the use of medical foster homes is expanding rapidly, creating an increased need for telehealth for these services that would result in closer follow up, more timely intervention and proactive care. We agree that many components of these services would be furnished from an authorized originating site and can be furnished via telehealth. Therefore, the Academy supports CMS's proposal to add CPT codes 90963-90966 to the list of telehealth services for CY 2016.

The Academy applauds CMS' continuing efforts to recognize the value to Medicare beneficiaries of telehealth services. We encourage CMS to expand its efforts on this front by removing some of its current restrictions in its PFS coverage guidelines, including the restriction of originating sites to those located in rural health professional shortage areas. The emergence and rapid growth of telehealth and mobile technologies designed to improve the health of individuals, enhance patient engagement and lower costs should be more fully recognized as it offers new opportunities to increase access to care in urban, suburban and rural areas. CMS should update its telehealth coverage guidelines, which date back to 2001, to reflect the current and future world of telehealth practice.

5. Incident to Proposals: Billing Physician as the Supervising Physician and Ancillary Personnel Requirements

CMS is proposing to clarify language around "incident to" billing to state that the physician or other practitioner who bills for incident to services must also be the physician or other practitioner who directly supervises the auxiliary personnel who provide the incident to services. They are also proposing to remove language that states that the physician (or other practitioner) supervising the auxiliary personnel need to be the same physician (or practitioner) upon whose professional service the incident to service is based. The Academy supports these proposed changes as we agree they provide clarity and it is important that the billing practitioner has a personal role in, and responsibility for, furnishing services for which they are billing and receiving payment as an incident to their own professional services.

6. Physician Compare Website

CMS proposes to make several changes to information available on the Physician Compare website, including: (1) expanding the section on each individual provider and group practice profile page that indicates Medicare quality program participation to include those who received an upward payment adjustment for the Value Modifier (VM); (2) continuing to make available on an annual basis all Physician Quality Reporting System (PQRS) Group Reporting Option measures for groups of two or more eligible professionals (EPs) in the year following the year the measures are reported; (3) continuing to make all PQRS measures across all individual EP reporting mechanisms available in the year following the year the measures are reported; (4) adding to the downloadable database for group practices and individual EPs the VM quality tiers and annotation of the payment adjustment received based on these tiers; and (5) adding utilization data to the downloadable database.

The Academy supports public reporting of performance rates on quality measures to help consumers choose their healthcare providers. We do have concerns about meaningful use of this data with respect to RDN Medicare providers as their patient sample size for PQRS measures often is limited as Part B MNT currently covered services are currently limited to beneficiaries with diabetes and renal disease. Therefore the Academy encourages CMS to make it clear to users of the website that lack of data on a provider may be due to low sample size and/or few measures available for reporting and is not necessarily a reason to not seek services from the provider. In addition, it is important to note that many PQRS measures represent the collective input of many providers involved in a beneficiary's care, as well as the beneficiaries themselves. For example, blood pressure and HbA1c control are impacted by primary and specialty care medical providers ordering practices, medical nutrition therapy, beneficiary compliance and other factors. Thus, lower quality outcomes may not be a direct reflection of an individual provider's health care practices. The Academy supports continued efforts by CMS at validation as well as consumer testing of information before it is posted as it is critically important that the information truly reflects quality of care and serves its intended purpose. The Academy also supports the addition of the proposed information to the downloadable database to assist providers and practices in their interpretation of reports and performance improvement efforts.

CMS also proposes to use a new methodology, the Achievable Benchmark of Care (ABC) methodology, to derive an item or measure level benchmark to assign stars for the Physician Compare 5-star rating. The Academy supports use of this new methodology for the reasons cited by CMS, namely because the benchmark represents quality while being both realistic and achievable; it encourages continuous quality improvement; and, it is shown to lead to improved quality of care. We would caution CMS, in selecting any benchmark, to consider how the methodology accounts for patients with multiple comorbidities or high complexity. Under the current Star system, members practicing in certain care settings, such as dialysis centers, have noted a trend toward units having patients with multiple co-morbid diagnoses/more complex cases receiving lower star ratings. This same situation could occur with Physician Compare and consumers may not recognize how to interpret the data.

CMS is also seeking comments about whether or not to add Medicare Advantage information to Physician Compare individual EP and group practice profile pages. The Academy supports adding Medicare Advantage information to the Physician Compare individual EP and group practice profile pages as to the plans the provider/practice accepts. In 2015, 31 percent of the 55 million people on Medicare are enrolled in a Medicare Advantage plan. From 2004 to 2015 this number has more than tripled.9 With such large numbers of Medicare beneficiaries involved, posting such information will assist consumers in making informed health care decisions, such as selection of providers.

7. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting System (PQRS)

While RDNs currently only qualify as eligible providers (EPs) under PQRS, the Academy supports CMS's continued efforts to align all of its quality improvement programs, reporting systems and quality measures. We believe this alignment will lighten the administrative burden on EPs while harmonizing the various CMS quality programs.

CMS proposes to continue to require individual EPs to report at least nine measures, covering at least three of the NQS domains AND report each measure for at least 50 percent of the EPs Medicare Part B Fee-for-service patients seen during the reporting period to which the measure applies to meet the criteria for satisfactory reporting for the CY 2018 payment adjustment. If the EP sees at least one Medicare patient in a face-to-face encounter, the EP will report on at least one cross-cutting measure. If less than nine measures apply to the EP, the EP would report on each measure that is applicable and be subject to the MAV process. As a specialty provider currently only able to direct bill for MNT services for Medicare beneficiaries with diabetes and renal disease, the number of PQRS measures that an RDN might report is limited and falls below the 9 measure threshold. As a result, the agency will continue to routinely incur the administrative burden of the MAV process for all RDN Medicare providers reporting in the PQRS. As the number of RDNs participating in the PQRS continues to grow, so too will this administrative burden on CMS. The Academy urges CMS to consider an alternate, lower reporting requirement for highly specialized Medicare providers with a limited scope of services and therefore limited applicable measures on which to report.

CMS proposes to replace PQRS#173 "Preventive Care and Screening: Unhealthy Alcohol Use-Screening" with "Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling" as it represents a more clinically robust measure and is broadly applicable to many specialties. CMS proposes adding this new measure to the set of cross-cutting measures. The Academy supports the replacement of this PQRS measure and its addition as a cross-cutting measure as it meets the intent of and criteria for this measure set.

CMS proposes several changes to the requirements for the Qualified Clinical Data Registry (QCDR) used for PQRS reporting, including: (1) opening the QCDR self-nomination period and keeping it open through 5:00 pm EST on January 31 of the year in which the clinical data registry seeks to be qualified, providing an additional month to self-nominate; (2) for an entity to become qualified for a given year, the entity must be in existence as of January 1 the year for which the entity seeks to become a QCDR; (3) allowing QCDRs to attest during the data submission period that the quality measure results and any and all data including numerator and denominator data provided to CMS will be accurate and complete using a web-based check box mechanism in lieu of submitting an attestation statement via email; and (4) requiring an entity who intends to participate in PQRS as a QCDR to submit all applicable documents that are necessary to analyze the vendor for qualification (e.g., data validation plan, measure specifications) by no later than January 31 of the year in which the vendor intends to participate. The Academy supports the proposed changes as they would ease the application process for entities seeking to become QCDRs.

One of CMS's goals, as indicated in the Affordable Care Act, is to report data on race, ethnicity, sex, primary language, and disability status. A necessary step toward fulfilling this mission is the collection and reporting of quality data, stratified by race, ethnicity, sex, primary language, and disability status. CMS intends to require the collection of these data elements within each of the PQRS reporting mechanisms. Although CMS is not proposing in this proposed rule to require the collection of these data elements, they are seeking comments regarding the facilitators and obstacles providers may face in collecting and reporting these attributes. The Academy 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. 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.

In addition, when collecting data on race, it is important to consider who will determine the categories to be used and the selection of the category for a specific Medicare beneficiary. Will the provider be asked to select the category or will the patient self-report? Oftentimes assumptions about race may be made by the provider. There also needs to be enough categories 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.

8. Potential Expansion of the Comprehensive Primary Care (CPC) Initiative

While CMS is not proposing to expand the CPC initiative at this time, the agency is soliciting public comments to receive information about issues surrounding a potential expansion of the program. Members of the Academy are working with primary care practices in the existing CPC regions to meet the health care needs of the populations being served. These RDNs are not only direct providers of MNT services, but are also assuming roles as care managers, quality improvement team leaders, patient registry managers, health coaches and more. The blended compensation model of the CPC initiative is creating opportunities for these primary care practices to expand their care teams to include RDNs to leverage their proven effectiveness at improving health outcomes related to chronic conditions, enhancing patient satisfaction, and reducing health system costs. MNT provided by RDNs for prevention, wellness and disease management can improve a patient's health and increase productivity and satisfaction levels through decreased doctor visits, fewer hospitalizations and re-admissions, and reduced prescription drug coverage. By using their expertise and extensive training, RDNs deliver care that is coordinated and cost-effective in a variety of chronic diseases, such as obesity, hypertension, diabetes, disorders of lipid metabolism, HIV infection, unintended weight loss in older adults and chronic kidney disease.10 RDNs are the most qualified food and nutrition experts, according to the Institute of Medicine (IOM), most physicians, and the US Preventive Services Task Force (USPSTF) and provide nutrition care more effectively at a lower cost than physicians, nurse practitioners, and physician assistants.11 Including RDNs as part of a comprehensive health care team also enhances the ability of all providers to practice at the height of their scope of practice.

Based on the experience of the Academy members participating in the CPC initiative (some of whom are also physicians) and/or supporting the existing learning collaboratives, the Academy recommends that the program should expand to both existing and new regions, with the caveat that the best practices from the most successful regions are encouraged to be implemented. Results to date from the CPC initiative reveal wide variability in specific performance measures across regions. Learnings from the existing practices should be used to inform expansion efforts. In addition, adequate funding is essential to support more extensive evaluation and data analysis efforts designed to better understand key attributes of high performing practices. Any expansion of the CPC initiative should definitely be done in parallel with state primary care transformation initiatives as long as this approach does not lead to duplication of efforts. Similar to CMS's rationale for aligning quality reporting across incentive programs, when states already have in place their own primary care transformation initiatives, it becomes challenging for all stakeholders (providers and payers) when such initiatives do not align well. Adding the CPC initiative on top of these other programs without regard to alignment has the potential to exacerbate the problem. Finally, in terms of the readiness of the private sector to respond to the need for support to practices to provide the five comprehensive primary care CPC functions in a potential expansion of the CPC initiative, the Academy is prepared to respond in several ways. First, the Academy can help practices find RDNs to work with them to manage care for patients with high health care needs due to multiple chronic conditions, deliver preventive MNT services, engage patients and caregivers in chronic disease self-management, and coordinate food and nutrition needs across the medical neighborhood. The Academy also prepared to provide technical support to practices as they look to integrate RDNs into their care teams. Such support may include sample position descriptions, business models, billing resources, competency assessment tools, evidence-based practice guidelines, nutrition education program assessment tools, client and professional education resources, and more.

9. Value-Based Payment Modifier (VM) and Physician Feedback Program

CMS proposes not to apply the VM to any type of non-physician EP who is not a PA, NP, CNS, or CRNA for the CY 2018 payment adjustment due to provisions in MACRA since payment adjustments under the Merit-based Incentive Payment System (MIPS) would not apply to them until 2021. The Academy supports this change in the timeline for implementing the VM to all non-physician eligible providers as it allows a more coordinated transition to the MIPS. AS CMS continues to roll out the VM to non-physician EPs as well as the MIPS, the Academy encourages CMS to work with all of the non-physician specialty societies to develop guidelines that take into account the unique needs of these provider communities because their volume of Medicare patients and claims, as well as their pool of PQRS measures, are much more limited than many of the general physician and non-physician (i.e., PA, NP, CNS, CRNA) EPs.

10. The Merit-based Incentive Payment System (MIPS)

CMS is not offering any specific rules related to this new system, but rather is looking for input in advance of issuing a formal Request for Information. CMS is interested in comments on the appropriate low-volume thresholds for purposes of excluding certain EPs from the definition of a MIPS eligible professional and activities that could be classified as clinical practice improvement activities. Clinical practice improvement activities are defined as "activities that relevant eligible professional organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that, when effectively executed, are likely to result in improved outcomes." Subcategories include: expanded practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, and participation in an alternative payment model.

The Academy overall urges CMS to consider the needs of non-physician providers when designing the Merit-based Incentive Payment System (MIPS). Based on 2013 data, approximately 17 percent of EPs for the PQRS are "other professionals" (meaning not an MD, DO, NP, PA, or CRNA).12 These providers render critical services to Medicare beneficiaries that improve health outcomes, enhance patient satisfaction, and control spending. As vital components of the Medicare system, they deserve the opportunity to earn incentive payments in a manner that recognizes unique differences in practice and available quality reporting measures so as to 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 risks losing these providers from the system, creating access to care problems for beneficiaries. In these days of concerns over provider shortages, it would be prudent to retain as many high performing professionals as possible within the Medicare program so as to effectively address the health needs of the Medicare population. The Academy recommends CMS convene a Technical Expert Panel (TEP) comprised of individuals representing these "other professionals" to inform development of the MIPS to meet their 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.

Although the Academy does not presently have a recommendation regarding an appropriate low-volume threshold, we do recommend that any thresholds that are set be statistically valid so that upward or downward payment adjustments are based on reliable and valid data. We do not recommend using a minimum amount of billed charges under Medicare Part B as a criteria due to the wide variability in fees for services under the PFS.

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 be sure to incorporate activities so as to provide options that meet 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.

The Academy also recommends CMS allow Medical Nutrition Therapy (MNT) and Diabetes Self-Management Training (DSMT) be allowed on the same date of service as a clinical practice improvement activity. Current regulations, which do not allow DSMT and MNT to be provided on the same date of service, burden quality and access to care and creates undue hardships for persons with diabetes, especially for disparate populations. Many Medicare beneficiaries forego necessary DSMT and MNT care because they cannot schedule services on the same day. CMS has cited the dual positive impact of both DSMT and MNT Medicare services for qualifying individuals with diabetes, and has acknowledged data indicating that, "provision of both Medicare benefits may be more medically effective for some beneficiaries than receipt of just one of the benefits." MNT and DSMT are distinct from each other, but are both necessary for improved beneficiary health outcomes. Further, same day provision allows for more effective multidisciplinary care.13 A regulatory change would allow beneficiaries to consolidate often-difficult and increasingly expensive trips to ambulatory care settings to receive care.

The current regulation limiting same day DSMT/MNT services creates burdensome impediments to quality patient-centered care and increases health care costs. Associated diabetes education and disease management by non-physician providers saves money and decreases healthcare utilization.14 Compared with no prevention, self-management reduces a high-risk person's 30-year chances of getting diabetes by about 11 percent, the chances of a serious complication by 8% and the chances of dying of a complication of diabetes by 2.3 percent.15 With the flexibility of having both services available on the same day, the likelihood of beneficiaries maintaining their appointments will increase. Preventive self-management, combined with reduced numbers of no-shows and lost days from work and school will result in significant cost savings to the health care system.

11. 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 45 "CY 2016 PFS Proposed Rule Estimated Impact on Total Allowed Charges by Specialty." CMS's omission of RDNs in Table 45 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.

In closing, current Medicare program policies do not allow registered dietitian nutritionists to practice as independent providers for the full scope of services for which RDNs are qualified and which are clinically indicated for Medicare beneficiaries, including MNT, Annual Wellness Visits, and intensive behavioral therapy for obesity and risk factors for cardiovascular disease. The Academy supports the IOM's recommendation in its report, Geographic adjustment in Medicare payment: Phase II: Implications for access, quality, and efficiency, that states "the Medicare program should support policies that would allow all qualified practitioners to practice to the full extent of their educational preparation."16 As CMS continues its efforts to achieve its goals of Better Care, Smarter Spending, and Healthier People, it is important that it sets policies that fully leverage the contributions of all members of the health care workforce, including both primary care and specialty care providers.

Thank you for your careful consideration of the Academy's comments on the proposals for the 2016 Medicare Physician Payment Schedule. Please do not hesitate to contact Jeanne Blankenship by phone at 202-775-8277 ext. 6004 or by email at jblankenship@eatright.org or Marsha Schofield at 312-899-4787 or by email at mschofield@eatright.org with any questions or requests for additional information.>

Sincerely,

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.

2Grade 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 Chronic Conditions among Medicare Beneficiaries: 2012 Chartbook. Accessed August 15, 2015.

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

5 Wigle P, Bloomfield HE, Tubb M, Doherty M. Updated guidelines on outpatient anticoagulation. Am Fam Physician. 2013 (Apr 15);87(8):556-566

6 Finkelstein et al. "Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates." Health Affairs, 28, no. 5 (2009). 27 July.

7 Ogden et al. Prevalence of Obesity in the United States, 2009-2010. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. January 2012.

8 Carmona, Richard. The Obesity Crisis in America. Surgeon General's Testimony before the Subcommittee on Education Reform, Committee on Education and the Workforce, United States House of Representatives. 16 July 2003.

9 http://kff.org/medicare/fact-sheet/medicare-advantage/ Accessed 24 August 2015.

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

11 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).

12 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.

13 Senator Mark Kirk letter to Donald Berwick, MD MPP, dated 23 September 2011, attached hereto (Quoting Centers for Medicare & Medicaid Services. NCD Decision Memo for Medical Nutrition Therapy Benefit for Diabetes & ESRD (CAG-00097N). Centers for Medicare & Medicaid Services Website.

14 See Robbins JM, Thatcher GE, Webb DA, Valdmanis VG. Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study. Diabetes Care. 2008;31(4):655-60; Boren SA, Fitzner KA, Panhalkar PS2; Specker, J. Costs and Benefits Associated with Diabetes Education: A Review of the Literature. The Diabetes Educator. 2009;31(1):72-96.

15 The Diabetes Prevention Program. DPP Results. 2008. Accessed June 1, 2009.