Academy Comments to CMS re Skilled Nursing Facility Quality Measures and Malnutrition

June 20, 2016

Andrew M. Slavitt, MBA
Acting Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-1645-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850

Re: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities Proposed Rule for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research (CMS-1645-P)

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the United States Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) regarding its proposed rule of April 25, 2016: "Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities Proposed Rule for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research (CMS-1645-P)". Representing more than 90,000 registered dietitian nutritionists (RDNs), dietetic technicians, registered (DTRs), and advanced-degree nutritionist researchers, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. Every day, we work with Americans in all walks of life — from birth through old age — conducting research and providing medical nutrition therapy (MNT)1 and other evidence-based nutrition counseling services that meet the health needs of all citizens.

The Academy largely supports the strategic vision and operational approach of the proposed rule to implement the IMPACT Act for skilled nursing facilities (SNFs), including specifying a potentially preventable readmission measure and defining performance standards and offers the following comments below. We also agree with CMS that "the implementation of the SNF VBP Program is an important step toward transforming how care is paid for, moving increasingly toward rewarding better value, outcomes, and innovations instead of merely volume."

A. Preventing Readmissions

The Academy shares CMS's concern that "[h]ospital readmissions among the Medicare population, including beneficiaries that utilize PAC, are common, costly, and often preventable.2,3 Almost 20% of Medicare beneficiaries were re-hospitalized within 30 days of discharge at an estimated cost of $17-26 billion dollars annually.4,5 Further, as CMS notes, MedPAC found that more than 75 percent of 30-day and 15-day readmissions and 84 percent of 7-day readmissions were considered "potentially preventable."6

The fragmentation of care among settings, acute care to rehab, to home, to primary care has been identified as a problem contributing to 30 day readmission to the acute care setting. Different methods for lowering 30 day all-cause readmissions have been proposed and examined including transitional care management7 and reengineered discharge programs.8 A few studies have looked at the risk factors associated with readmission such as weight loss or being underweight;9,10 other studies have assessed the impact of oral nutritional supplements (ONS) on readmission rates.11,12 We know that MNT and nutritional counseling by RDNs has a positive impact on weight management13 and chronic disease.14

1. Role of RDNs

RDNs can positively influence readmission rates with effective nutrition screening, assessment and interventions and are eager to be part of a value-based payment system in which they are held accountable for the outcomes of their effective services and receive benefits for delivering positive results for patients and payers. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) (Pub. L. 113-185) requires standardized patient/resident assessment data, and RDNs are preparing to address and devise nutrition care services and MNT required to meet the cross-setting quality measures. The Academy is in support of CMS's strategic implementation for public reporting of identified measures (e.g., pressure ulcers,15 skin integrity, readmissions, functional status, and falls management) and urges CMS to facilitate the provision of and payment for MNT when medically indicated across the continuum of care. We note that Agency for Healthcare Research and Quality (AHRQ) recognizes nutrition assistance listed as one of the listed to identify in the community as a transitional care service.16 Through screening, nutrition assessment, nutrition diagnosis, intervention, and monitoring, RDNs can identify factors such as chronic diseases and other factors that contribute to readmission, which could require a nutrition prescription and individualized plan of care.

The Academy established an IMPACT Taskforce to gather and assess information on the IMPACT Act– Post-Acute Care (PAC) based on the 3 aims of the HHS National Quality Strategy and CMS Quality Strategy's Goals. We look forward to sharing findings and efforts with you on a variety of issues in addition to readmissions measures, including identified measure domains for medication reconciliation and patient preferences related to food and nutrition care; learning modules and webinars detailing the IMPACT Act; standardized PAC assessment tools; a timeline for implementation; and focus on interoperability within electronic health records.

2. Promoting Care Coordination

We agree with CMS's intention in this proposed rule to "support SNF providers' efforts to promote care coordination and deliver high quality care at a lower cost to Medicare." The Academy agrees with CMS's philosophy 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. The Academy recognizes that the qualifications, skills, education, training, and credentials of the practitioner delivering the service is more important in assuring effectiveness than the service location, but appreciates that both current and newer models of health care delivery affirm the importance of the primary care provider (PCP) coordinating care, while recognizing that the PCP does not deliver all of the care.

The Academy encourages CMS's efforts effectuating 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."17 As CMS continues its efforts to achieve its goals, it is important that it sets policies to fully leverage the contributions of all highly qualified members of the health care workforce.

3. Impact of Malnutrition

Malnutrition is a leading cause of morbidity and mortality, especially among the elderly. Evidence suggests that 20 percent to 50 percent of patients are at risk for malnutrition or are malnourished at the time of hospital admission,18 resulting in a significant impact on patient outcomes, resource use, and costs. Furthermore, malnutrition may be exacerbated during hospital stays due to a variety of factors, including age, surgical procedures, and comorbidities. Malnutrition is most simply defined as any nutrition imbalance that affects both overweight and underweight patients alike and is generally described as either "undernutrition" or "overnutrition."19

A consensus statement by the Academy for Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN) further defines malnutrition as a presence of two or more of the following characteristics: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, or decreased functional status.20 While clinical guidelines recommend screening, assessment and diagnosis, nutritional intervention, education/counseling, discharge planning and use of care plans for patients who are malnourished or at high risk of being malnourished, evidence suggests a gap remains in the delivery of care.21,22,3,24

Patients who are malnourished while in the hospital have an increased risk of complications, readmissions, and length of stay, which is associated with up to a 300 percent increase in costs.25 Furthermore, research suggests initiatives that target improving quality of care related to malnutrition in the hospital setting can reduce the burden of malnutrition in the hospital and improve patient outcomes.26,27

B. SNF 30-Day Potentially Preventable Readmission Measure (SNFPPR)

The Academy offers the following comments specific to particular aspects of the proposed SNF 30-Day Potentially Preventable Readmission Measure (SNFPPR).

1. Support Harmonizing of Measures

The proposed rule strives to ensure, "as appropriate, the proposed potentially preventable hospital readmission measure for SNFs is being harmonized with similar measures being proposed for LTCHs, IRFs, and HHAs to meet the requirements of the [IMPACT Act]." The Academy supports CMS's ongoing efforts to coordinate across CMS programs, as well as with initiatives in other public programs and in the private sector. We have noticed the efforts CMS has been making to break down programmatic silos to promote consistency, and we are pleased to report that our experience indicates the efforts have been successful thus far. We also support CMS's ongoing efforts to engage private payers and other stakeholders to develop consensus around core sets of quality measures that would be used by all payers is wise and should lead to greater consistency and efficiency.

2. Maintain Quality

The Academy seeks clarification regarding the extent to which the proposed improvement score "based on how much [an SNF's] performance on the specified measure during the performance period improved from its performance on the measure during the baseline period" conflicts with CMS's decision that "[i]n determining what level of SNF performance would be appropriate to select as the performance standard for the quality measures specified under the SNF VBP program, [it] focused on selecting levels that would challenge SNFs to improve continuously or to maintain high levels of performance." (Emphasis added.) As performance standards are selected, the Academy encourages CMS to ensure that it designs a system that rewards not only continuing improvement, but consistently high performing facilities as well. When facilities become high performers, their margin for continued improvement diminishes, but their contributions to quality, cost-effective care are still worthy of recognition and incentivizing. Maintaining a high level of performance should be rewarded in addition to rewarding new improvements in performance.

3. Burden of Reporting

The Academy is concerned with potential additional burdens imposed upon providers and facilities as quality measures are implemented. We are pleased to note that in the proposed rule, measures are claims-based, which will not require additional data collection or add to the submission burden for SNFs or practitioners.

4. Diversity

The Academy supports efforts to reduce health disparities and appreciates CMS's "concerns about holding providers to different standards for the outcomes of their patients of diverse sociodemographic status because [it does] not want to mask potential disparities or minimize incentives to improve the outcomes of disadvantaged populations." In addition, we support CMS's decision to "routinely monitor the impact of sociodemographic status on providers' results on [its] measures."

C. Conclusion

The Academy sincerely appreciates the ongoing opportunity to offer comments to HHS and CMS on the specification of a potentially preventable readmission measure for the SNF and VBP program and other proposals related to this implementation of the IMPACT Act. We would be grateful for an opportunity to discuss the Academy's IMPACT Act Task Force with your team and continue our collaboration on future initiatives. Please contact either Jeanne Blankenship by telephone at 202/775-8277, ext. 1730 or by email at or Pepin Tuma by telephone at 202/775-8277, ext. 6001 or by email at with any questions or requests for additional information.


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

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics

1 Medical nutrition therapy (MNT) is an evidence‐based application of the Nutrition Care Process. According the Academy's definition, the provision of MNT (to a patient/client) may include one or more of the following: nutrition assessment/ re-assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation that typically results in the prevention, delay or management of diseases and/or conditions. [Academy of Nutrition and Dietetics Definition of Terms List. Available at . Accessed March 1. 2016.] The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans. Further, the Academy's definition of MNT is broader than the definition of MNT in the Social Security Act (42 U.S.C. 1395(vv)(1)).

2 Friedman B, Basu J. The rate and cost of hospital readmissions for preventable conditions. Med Care Res Rev. 2004;61(2):225-40

3 Jencks, S.F., Williams, M.V., and Coleman, E.A.: Rehospitalizations among patients in the Medicare Fee-for-Service Program. N. Engl. J. Med. 360(14):1418-1428, 2009. doi:10.1016/j.jvs.2009.05.045.

4 Dartmouth Atlas Project, PerryUndem Research & Communications. The Revolving Door: A Report on U.S. Hospital Readmissions. Princeton, NJ: Robert Wood Johnson Foundation; 2013. Accessed January 13, 2016.

5 Medicare Payment Advisory Committee (MEDPAC). Report to the Congress: Medicare and the Health Care Delivery System. Washington, DC: MedPAC; 2013.

6 MedPAC: Payment policy for inpatient readmissions, in Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC, pp. 103-120, 2007. Available from

7 Naylor MD, Hirschman KB, O'Connor M, Barg R, Pauly MV. (2013). Engaging older adults in their transitional care: what more needs to be done? J Comp Eff Res. 2013 Sep;2(5):457-68.

8 Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, Forsythe SR, O'Donnell JK, Paasche-Orlow MK, Manasseh C, Martin S, Culpepper L. A reengineered hospital discharge program to decrease rehospitalizations: a randomized trial. Ann Intern Med. 2009 Feb 3;150(3):178-87.

9 Allaudeen N, Vidyarthi A, Maselli J, et al. Redefining Readmission Risk Factors for General Medicine Patients. J Hosp Med 2011; 6: 54-60.

10 Mudge AM, Kasper K, Clair A, Redfern H, Bell JJ, Barras MA, Dip G, Pachana NA. Recurrent Readmissions in Medical Patients: A Prospective Study. J Hosp Med. 2011 Feb;6(2):61-7.

11 Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006; 119(8):693-699. See more at:

12 Norman K, Kirchner H, Freudenreich M, Ockenga J, Lochs H, Pirlich M. Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease—a randomized controlled trial. Clin Nutr. 2008 Feb;27(1):48-56. See more at:

13 Raatz SK, Wimmer JK, Kwong CA, Sibley SD. Intensive diet instruction by registered dietitians improves weight-loss success. J Am Diet Assoc. 2008 Jan;108(1):110-3.

14 Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. J Am Diet Assoc. 2006 Jan;106(1):109-12.

15 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Treatment of pressure ulcers. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2014. p. 126-208.

16 Hospital Guide to Reducing Medicaid Readmissions. (Prepared by Collaborative Healthcare Strategies, Inc., and John Snow, Inc., under Contract No. HHSA290201000034I). Rockville, MD: Agency for Healthcare Research and Quality; August 2014. AHRQ Publication No. 14-0050-EF.

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

18 Barker LA, Gout BS, and Crowe TC. Hospital malnutrition: Prevalence, identification, and impact on patients and the healthcare system. International Journal of Environmental Research and Public Health. 2011;8:514-527.

19 Tappenden K, Quatrara B, Parkhurst, M et al. Critical role of nutrition in improving quality of care: An interdisciplinary call to action to address adult hospital malnutrition. Journal of Academy of Nutrition and Dietetics. 2013;113 (9): 482-497.

20 White JV, Guenter P, Jensen G, et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). Journal of Parenteral and Enteral Nutrition. 2012; 36:275-283.

21 Mueller C, Compher C, Ellen DM. A.S.P.E.N.Clinical guidelines: Nutrition screening, assessment, and intervention in adults. Journal of Parenteral and Enteral Nutrition. 2011;35(1):16–24.

22 NPUAP and EPUA Panel. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel Pressure Ulcer Treatment Quick Reference Guide. Washington, DC; 2009.

23 Thomas DR, Ashmen W, Morley JE, and Evans WJ. Nutritional management in long-term care: Development of a clinical guideline. The Journal of Gerontology. 2000;55(12):M725–34.

24 Weimann A, Braga M, Harsanyi L, et al. ESPEN guidelines on Enteral Nutrition: Surgery including organ transplantation. Clinical Nutrition (Edinburgh, Scotland). 2006;25(2):224–44.

25 Isabel TD and Correia M. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clinical Nutrition. 2003;22(3):235–239.

26 Brugler L, DiPrinzio MJ, & Bernstein L. The five-year evolution of a malnutrition treatment program in a community hospital. The Joint Commission Journal on Quality Improvement. 1999; 25(4):191–206.

27 O'Flynn J, Peake, H, Hickson, M, et al. The prevalence of malnutrition in hospitals can be reduced: results from three consecutive cross-sectional studies. Clinical Nutrition. 2005;24(6):1078–88.