Academy Comments to CMS re Merit Based Incentive Payment System and Alternative Payment Model Incentive

June 27, 2016

Andrew M. Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: CMS-5517-P
P.O. Box 8013
Baltimore, MD 21244-8013

Re: File Code-CMS-5517-P; Medicare Program; Merit Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule; and Criteria for Physician-Focused Payment Models

Dear Acting Administrator Slavitt:

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on CMS-5517-P Merit Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule; and Criteria for Physician-Focused Payment Models published in the May 9, 2016 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 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 Alternative Payment Models and associated payment incentives. 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 comments on the following aspects of the new Quality Payment Program:

  1. General Comments
  2. The Merit-Based Incentive Program System (MIPS)
    1. MIPS Eligible Clinician Identifier and Exclusions
    2. Quality Performance Category
    3. Resource Use Performance Category
    4. Clinical Practice Improvement Activities Performance Category
    5. Advancing Clinical Information Performance Category
    6. Performance Standards and Scoring
  3. Alternative Payment Models (APMs)

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. Overall the goals set forth under MACRA are lofty ones with a vision of a perfect world of health care delivery and patient engagement. As CMS works to implement the provisions of MACRA related to MIPS and APMs, the Academy overall urges CMS to consider the needs of non-physician providers. Based on 2014 data, "other professionals" (meaning not an MD, DO, NP, CNS, PA, or CRNA) represent a large and growing proportion of Eligible Professionals (EPs) for the Physician Quality Reporting System, increasing from approximately 17% in 2013 to nearly 24% in 2014.3 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 Quality Payment Program. 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 strongly recommends CMS convene a Technical Expert Panel (TEP) comprised of individuals representing these "other professionals" to inform adaptation of the Quality Payment Program to meet their needs before these professionals become eligible clinicians under this program. Representatives from the AMA 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 value-based payments and be held accountable for the outcomes of their effective services. Some RDNs are already participating in alternative payment models as part of some forward-thinking physician office practices as well as through some 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 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 that is heavily reliant on 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 and afford Medicare beneficiaries better opportunities for improved health through such proven effective services, the following are required to effectively design the Quality Payment Program:

  1. Physicians should be either mandated or incentivized to utilize non-physician providers such as RDNs.
  2. Non-physician providers, such as RDNs, need to 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 non-physician 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 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.4 RDNs are recognized as the most qualified food and nutrition experts by the National Academy of Medicine (NAM) (formerly the 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 reminds CMS of the NAM'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 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 Academy has overall concerns about the impact of the Quality Payment Program as proposed on solo practitioners and small practices (<15 providers). Throughout the proposed rules there are comments and provisions that indicate it is not CMS' intent to do so, yet in reality the complexities of the system in its proposed design and incentives for participation in APMs may effectively do so.

Also, while overall MACRA and the proposed rules set forth requirements intended to provide flexibility and support the needs of small practices, rural providers, and specialty providers, the Academy is concerned that it is being done through a physician-provider lens. As a result, CMS may not be maximizing opportunities to fully transform the delivery and payment systems to meets its stated goals. 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.

2. The Merit Based Incentive Program System (MIPS)

MIPS Eligible Clinician Identifier and Exclusions

CMS is proposing multiple identifiers for participation and performance, but using a single identifier, TIN/NPI, for applying the payment adjustment. CMS is proposing the same identifier be used for all four performance categories. The Academy agrees with using this methodology as it appears to be working well for existing Medicare incentive programs and adequately addresses eligible clinicians who may provide services as both an individual provider as well as part of one or more group practices. This methodology also supports effective health IT exchange.

CMS proposes to define a MIPS eligible clinician for the first 2 years of the program as a physician, physician assistant, nurse practitioner, clinical nurse specialist and certified registered nurse anesthetist, and a group that includes such professionals. The Academy supports this initial definition of a MIPS eligible clinician as such health care professionals represent the majority of current Medicare Part B providers and are currently best positioned for scoring under all four performance categories as defined under MACRA based on the historical path of regulatory and financial support under HHS programs. MACRA gives the Secretary the authority under section 1848(q)(1)(C)(i)(II) to expand the definition of MIPS eligible clinician to include additional eligible clinicians (as defined in section 1848(k)(3)(B) of the Act) through future rulemaking. Under the proposed rules, the "other professionals" noted under our "General Comments" above (including RDNs) are excluded from the definition of an eligible clinician for the first 2 years of the program. The Act requires the Secretary to permit any eligible clinician who is not a MIPS eligible clinician the option to volunteer to report on applicable measures and activities under MIPS and CMS strongly encourages these providers to do so to gain experience with the program to prepare for future eligibility. Such a statement implies that the MIPS will be rolled out to other Medicare Part B providers in a design similar to what is published in the finalized rule. The new Quality Payment Program must be designed in a manner from the outset that meets the needs of these essential health care providers, without whom the overarching goals of Better Care, Smarter Spending, and Healthier People cannot be achieved. Such providers should also be afforded the opportunity for a similar ramp-up period for payment adjustments as the initial cadre of eligible clinicians.

CMS proposes to exclude from the MIPS Medicare providers who are new Medicare-enrolled clinicians, clinicians who treat 100 or fewer Part B beneficiaries and have Medicare billing charges less than or equal to $10,000, and those significantly participating in an Advanced APM. The Academy supports the exclusion for first-year Medicare providers. While we support the intent of excluding low volume providers, we have serious concerns about the potential unintended consequences of this exclusion category. Based on data from the 2014 Reporting Experience Including Trends (2007-2015), Physician Quality Reporting System, the majority of RDN Medicare providers would be excluded from participation based on the number of Part B beneficiaries they treat.7 Payments to these RDNs would continue to fall under the Physician Fee Schedule (PFS). The Academy has major concerns that an unintended consequence of this scenario will be driving these proven effective providers out of the Medicare program as payments under the PFS will essentially decrease over time based on other provisions of MACRA. In addition, these providers will be disadvantaged as their only opportunity for earning incentive payments under the Medicare program will be through participation in APMs. As previously noted, it is still the exception for physician office practices to directly employ and/or contract with RDNs due to a lack of explicit recognition by CMS and other payers of the value of RDNs as part of the patient-centered health care team.

If the Secretary would exercise her authority under Section 1834 (n) (42 USC 1395(m))8 of the Social Security Act to modify the current Part B Medicare MNT benefit to include the diet-related chronic diseases Medicare beneficiaries experience it would go a long way toward achieving CMS's goals of Better Care, Smarter Spending, and Healthier People and avoiding a migration of RDN providers out of the Medicare program. 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.

Quality Performance Category

The Academy supports the retention of all current PQRS reporting mechanisms under the MIPS as proposed by CMS. Claims-based reporting continues to be the reporting mechanism of choice by RDN eligible providers in PQRS as practice resource constraints, along with the lack of financial incentives from CMS, discourage these providers from adopting EHR technology or utilizing the registry-reporting option.

In terms of reporting criteria under MIPS, the Academy supports the proposed changes in reporting requirements from a minimum of 9 measures to 6, removing the requirement to report across multiple National Quality Strategy domains, and to include one crosscutting measure and one outcome measure (if available) or other high quality measure. We also support CMS' efforts to align with the private sector, reduce the reporting burden, and use all-payer data where possible. As the Academy and other Medicare providers have noted in responses to previous rule-making under the PFS, many eligible providers under the PQRS do not have 9 measures to report, thus creating an administrative burden on CMS through application of the MAV process.

While we support the general direction proposed by CMS for the Quality performance category, the Academy continues to have concerns that the current set of quality measures does not provide 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.

CMS is seeking comments on what specific measures of over or under use should be included as appropriate use measures. The Academy recommends development and inclusion of an appropriate use measure on referrals to RDNs for MNT services for patients with nutrition-related chronic conditions 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.9 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.10 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 efficient and an integral component of treatment. Given the low utilization of this service 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.

The Academy of Nutrition and Dietetics is a member of the Alliance of Wound Care Stakeholders ("Alliance"), a nonprofit multidisciplinary trade association of physician medical specialty societies and clinical associations whose mission is to promote quality care and access to products and services for people with wounds through effective advocacy and educational outreach in the regulatory, legislative, and public arenas. Many RDNs are members of the multi-disciplinary team of heath care professionals who treat Medicare patients with chronic wounds since nutrition is a very important component of wound healing.

In 2014, the Alliance worked with the Chronic Disease Registry (d/b/a the U.S. Wound Registry or USWR), a CMS recognized Qualified Clinical Data Registry, to create wound care quality measures, one of which is a nutrition process measure (Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers). It is our understanding that out of the 200 PQRS measures that CMS has identified as being able to contribute to the Quality Reporting Score, these QCDR wound care measures are not included. We believe that instead of wound care physicians reporting generic measures, they should be able to report quality measures such as this important one regarding nutrition that are relevant to their practices. We recommend, based on the prevalence rate and escalating costs of care of chronic non healing wounds, that CMS allow wound care physicians to utilize the Alliance's QCDR measures to satisfy the quality measure requirements under MIPS.

Finally, the Academy seeks clarity around the proposed change in PQRS#128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan to remove the upper parameter from the measure description to align with recommendations of technical expert panel and clinical expertise. We recognize BMI norms for individuals age 65 years and older have been called into question as numerous studies suggest that a "higher" BMI in older persons is associated with longevity and has not been proven detrimental to health.11,12 However, without normal parameters included in the measure description, how will providers know when to document a follow-up plan?

Resource Use Performance Category

The Academy supports CMS in not proposing any data submission requirements for the resource use performance category, but rather to use administrative claims data to calculate the eligible clinician’s performance score. We agree that such a system is logical and reduces administrative burden on the providers/practices. We also agree with CMS's proposed plan to not calculate a resource use performance category score if a MIPS eligible clinician in not attributed any resource use measures.

Clinical Practice Improvement Activities Performance Category

The Academy supports inclusion of the clinical practice improvement activities (CPIA) category into MIPS and supports the proposed use of a "yes/no" response for year 1. We also support the proposed provisions to accommodate small practices and practices located in rural areas, or geographic HPSAs as we believe such adjustments will enable these providers to successfully participate in this important component of the program.

Upon reviewing the CPIA Inventory included in Table H of the proposed rules, we agree with the proposed assignment of medium and high weights to activities within each category. While the list of proposed activities is extensive and in theory offers reporting flexibility to eligible clinicians, the Academy recommends CMS work with non-physician Medicare providers to adapt the list to better meet their needs and more appropriately capture their role on the patient-centered health care team. Section 1848(q)(2)(C)(v)(III) of MACRA defines a CPIA "as an activity that relevant eligible clinician organizations and other relevant stakeholders identify as improving clinical practice or care delivery, and that the Secretary determines, when effectively executed, is likely to result in improved outcomes." While one of the strategic goals of MIPS is to use design incentives that drive movement toward APMs, once again the system must roll out in a manner that recognizes the challenges faced by non-primary care health care professionals to become integrated into APMs.

The Academy has completed work on CPIA 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 CPIA component within the MIPS program. The MIPS CPIA 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 CPIA inventory and allow RDNs to report CPIA activities through this tool when they become eligible clinicians under MIPS.

Specifically, the Academy recommends CMS consider including in the CPIA Inventory under Population Management, integrating a registered dietitian into the care team or referrals to RDNs for MNT services for patients with nutrition-related chronic conditions. This CPIA is evidence-based and 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.

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.13 RDNs are recognized as the most qualified food and nutrition experts by the National Academy of Medicine (formerly the 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.14

The Academy also strongly encourages CMS to allow MNT and Diabetes Self-Management Training (DSMT) be allowed on the same date of services as a CPIA. Current regulations around these services are another example of a serious disconnect between theory in this set of proposed rules and other current regulatory constraints. Several activities under the proposed CPIA inventory subcategories of Care Coordination and Beneficiary Engagement incentivize self-management services, which by definition includes DSMT. Existing Medicare regulations do not allow DSMT and MNT to be provided on the same date of service, thus burdening quality and access to care and creating undue hardships for persons with diabetes. Many Medicare beneficiaries forgo 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.15 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.16 Compared with no prevention, self-management reduces a high-risk person's 30-year chances of getting diabetes by 11 percent, the chances of a serious complication by 8 percent and the chances of dying of a complication of diabetes by 2.3 percent.17 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.

CMS seeks public comments on two additional subcategories for future consideration:

  • Promoting Health Equity and Continuity, including serving Medicaid beneficiaries, including individuals dually eligible for Medicaid and Medicare; accepting new Medicaid beneficiaries; participating in the network of plans in the Federally Facilitated Marketplace or state exchanges; and maintaining adequate equipment and other accommodations to provide comprehensive care for patients with disabilities.
  • Social and Community Involvement, such as measuring completed referrals to community and social services or evidence of partnerships and collaborations with community and social services.

The Academy supports inclusion of both of these subcategories in the future and recommends for the latter one 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 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 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.

Advancing Care Information Performance Category

The Academy supports the intention under MACRA to include the Advancing Care Information category under the MIPS. We agree with the overall proposal that allows clinicians to choose to report a customizable set of measures that reflects how they use EHR technology in their day-to-day practice and moves away from the previous all-or-nothing EHR measurement or quality reporting. We also support CMS's proposal for the first year, for non-physician clinicians who have not been eligible to participate in the Medicare and/or Medicaid EHR Incentive Program, to assign a weight of zero to this performance category if the clinician does not submit any data for any of the specified measures.

The Academy is committed to embracing adoption and optimization of Health Information Technology (health IT) to improve health and health care in the United States. Despite not being considered as an Eligible Professional (EP) in the EHR Meaningful Use program, the Academy has been an active participant in the policy, standards and vocabulary proceedings. We have participated in the Health Information Technology for Economic and Clinical Health (HITECH) initiatives since 2009, including presence at a majority of the face-to-face Health IT Standards Committee and Policy Committee meetings held in Washington, DC; have commented in writing and in-person; and have actively participated in Office of the National Coordinator (ONC) Initiatives for development and harmonization of standards, vocabularies and policies. The Academy continues to align existing nutrition care processes and strategies in order to adjust to rapidly evolving regulations for electronic health records (EHR).

We have led or actively participated in development of health IT standards and interoperability projects which we hope will contribute to nationwide exchange of nutrition data for patient care, population health and improved outcomes. Contributions of 50+ volunteers, staff and consultants have allowed us to continually advocate for nutrition inclusion in health information technology. In particular, we remain committed to those initiatives which we believe will help us contribute to an improved health care system and optimal nutritional status for individuals and the population as a whole.

The Academy has participated in Health Level Seven (www.hl7.org) standards development consistently since 2010. Our strategy has been to advocate for nutrition inclusion in cross-cutting, balloted standards in efforts to document nutrition care across care situations and settings. Efforts are directed at assuring nutrition inclusion where possible in guidance from the Office of the National Coordinator of Health IT, and in particular, standards identified in the 2015 Edition Health IT Certification Criteria18, the 2016 Interoperability Standards Advisory19, and in subsequent guidance which supports nationwide interoperability. The Academy has focused on nutrition inclusion in health IT standards which support transitions of care across care settings; this includes nutrition sections in the now mandated HL7 Consolidated Clinical Document Architecture Release 2.1. Likewise value sets which support nutrition care using this critical standard are now in development. We are dedicated to providing the necessary foundation so that patients do not experience readmissions, delays in treatment or further compromised nutrition status as a result of nutrition data left out of transitions of care documents.

Since RDNs have not been EPs under Meaningful Use, the Academy encourages CMS to expand its existing programs of financial and technical support to all such providers to help them achieve not just successful performance under the Quality Payment Program, but more importantly to achieve the overall benefits of leveraging health information technology into our nation's health care delivery system. As already noted, the Academy considers it critical to the future success of the Quality Payment Program to design all components of the program to respect the roles of all qualified health care professionals and to meet their needs, no matter the size or location of the practice. We have concerns that after the first year of the program, without the necessary financial and technical support, major provider types will not be able to report measures under all six objectives as doing so may not fall under their current scope of practice and state laws. For example, RDNs as a provider type will not be able to report under Electronic Prescribing or Public Health and Clinical Data Registry Reporting. While CMS has proposed processes to reweight categories based on the applicability of components to specific providers, we have concerns that the degree of reweighting that may be necessary across the four performance categories for certain provider types may create undesirable inequities within the system that could lead to a mass exodus of Medicare providers. For this specific performance category, the model of support that has been in place for physicians could be expanded to other provider types to proactively address this concern.

Performance Standards and Scoring

The Academy is pleased that CMS is proposing a performance scoring system in an effort to keep clinician flexibility and administrative burden in mind. As already stated in our comments, the Academy is pleased to note how CMS has implemented the provisions under MACRA to assign different scoring weights (including a weight of zero) from those that apply generally under the MIPS if there are not sufficient measures and activities applicable and available to each type of eligible clinician. At the same time, we are concerned that in an effort to build in flexibility CMS is not achieving one of its desired goals of creating a program that is understandable. Extensive and ongoing education, training and technical assistance most likely will be required to ensure eligible clinicians fully understand how the Quality Payment Program works and how to successfully establish and implement appropriate reporting systems within their practices. Once again, before expanding the definition of eligible clinicians to include other categories of Medicare providers, this aspect of design of the MIPS would benefit from the creation of Technical Expert Panels.

The Academy supports CMS in its proposals to allow MIPS eligible clinicians the option to report as an individual or as part of a group. We are pleased to see the variety of data submission mechanisms available for reporting under each performance category, including self-attestation for the Advancing Clinical information and CPIA performance categories. Qualified registries, QCDRs, EHRs or other health IT systems are not designed to capture and report on CPIA data, nor should they be expected to be redesigned to do so. The Academy also supports CMS's proposal to allow MIPS eligible clinicians to submit information via multiple mechanisms while allowing use of only one submission mechanism per category. This proposal provides appropriate and necessary flexibility needed by a diverse range of practice size and resources of the Medicare provider community.

CMS seeks comments on how often providers want to receive performance feedback reports and whether or not they should include CPIA and Advancing Care Information performance data. The Academy recommends providing quarterly feedback reports if possible to provide clinicians with regular, timely feedback that supports continuous practice improvement. We also recommend providing feedback on all four performance categories to allow clinicians to understand their performance across the entire Quality Payment Program.

It is evident in the proposed rules that CMS has grappled with the issue of how best to recognize a high level of performance as well as achieving improvements in performance. The Academy continues to encourage CMS to be careful not to design the system in such a way that it only rewards continuing improvement. Such a goal becomes difficult under the statutory requirement for budget neutrality, but is critical to provider participation and retention. As practices become high performers, their margin for continued improvement diminishes. Yet their contributions to quality, cost-effective care are still worthy of recognition. One of the flaws of some of the Medicare ACO models is that high performers ended up paying money back to CMS, despite the fact that they had high Star ratings. As a result, some of these organizations stopped participating in these programs.

3. Alternative Payment Models

As noted above, the Academy overall urges 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" PCMH rather than being employed by the entity. In addition, APMs tend to require the use of certified EHR 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 (TEP) comprised of individuals representing these "other professionals" to inform efforts to offer incentive payments for participation in APMs before these professionals become eligible clinicians under the Quality Payment Program. 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. We would 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.

RDNs are eager to be part of value-based payments and be held accountable for the outcomes of their effective services. Some RDNs are already participating in alternative payment models as part of some forward-thinking physician office practices as well as through some 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 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 that is heavily reliant on referrals to RDNs who work in their own non-physician practice settings.

Thank you for your careful consideration of the Academy's comments on these proposed rules. 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. Please do not hesitate to contact Jeanne Blankenship by phone at 202-775-8277 ext. 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.

Sincerely

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

Marsha Schofield, MS, RD, LD, FAND
Senior Director
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 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 2014 Reporting Experience Including Trends (2007-2015), Physician Quality Reporting System. April 15, 2016. Centers for Medicare & Medicaid Services.

4 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Effectiveness Systematic Review 2009, 2013-2015.

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.

7 2014 Reporting Experience Including Trends (2007-2015), Physician Quality Reporting System. April 15, 2016. Centers for Medicare & Medicaid Services.

8 (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. (1) modify—
    1. 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
    2. 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

9 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Effectiveness Systematic Review 2009, 2013-2015.

10 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).

11 Winter JE, MacInnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause mortality in older adults: a meta analysis. Am J Clin Nutr. 2014Apr;99(4):875-90. doi: 10.3945/ajcn.113.068122.

12 Flegal KM, Kit BK, Orpana H, Graubard B. Association of all-cause mortality with overweight and obesity using standard body mass index categories. JAMA. 2013;309(1):71-82. Doi: 10.1001/jama.2012.113905

13 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Effectiveness Systematic Review 2009, 2013-2015.

14 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).

15 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.

16 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.

17 Ibid

18 https://www.healthit.gov/policy-researchers-implementers/2015-edition-final-rule

19 https://www.healthit.gov/sites/default/files/2016_InteroperabilityStandardsAdvisoryFINAL.pdf