Academy Comments to Healthy People 2020 re Increasing MNT Utilization for Chronic Kidney Disease

November 16, 2015

Don Wright, M.D., M.P.H.
Deputy Assistant Secretary for Health
Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
Attn: Public Comment
1101 Wootton Parkway, Room LL-100
Rockville, MD 20852

Dear Dr. Wright,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit these comments to the Office of Disease Prevention and Health Promotion (ODPHP) at the United States Department of Health and Human Services (HHS) related to its October 15, 2015 "Announcement of Solicitation of Written Comments on Modifications of Healthy People 2020 Objectives." The Academy proposes to offer new Healthy People 2020 objectives to the existing critical public health issue topic of Chronic Kidney Disease (CKD) related to the utilization of and access to Medicare Part B's CKD Medical Nutrition Therapy (MNT) service.

Representing more than 90,000 registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. RDNs provide medical nutrition therapy in dialysis facilities, clinics, hospitals, university settings, and private practice. Through their direction and leadership, RDNs strive to advance the nephrology nutrition clinical practice, education, and research while promoting continuing education programs for dietitian nutritionists and other healthcare professionals.

New CKD Objectives: Increase MNT Utilization by Medicare Beneficiaries

America's health care system could save significant resources and improve health by preventing and treating chronic diseases with demonstrably effective nutrition care services. As ODPHP notes, one of the major goals of the HP2020 program is to "reduce new cases of chronic kidney disease and its complications, disability, death, and economic costs." According to ODPHP, ESRD is a disease that “greatly affects an individual's quality of life, and is an enormous burden on the healthcare system, [with ESRD alone] accounting for approximately 6.3 percent ($33 billion) of total Medicare costs." When combined with the additional costs of treating CKD, ESRD and CKD consume nearly 25 percent of the Medicare budget.2 The annual mean expenditure for an ESRD patient treated with dialysis and transplant is $70,000 per patient,3 whereas Medicare costs for CKD patients in 2012 totaled $20,162 per patient.4,5 Thus, it is a prudent investment to identify and encourage clinically effective and cost-effective strategies, such as MNT, for delaying dialysis and treating CKD.

MNT provided by RDNs is a widely recognized component of medical guidelines for the prevention and treatment of many chronic diseases, including renal disease, as well as in the reduction of risk factors for these conditions. Medicare has reimbursed MNT for CKD since 2002, but is presently underutilized. 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.6

Increasing Medicare Part B utilization of MNT for CKD meets the enumerated Healthy People 2020 criteria for proposing additional objectives. MNT is a demonstrably successful preventive treatment to encourage behavior modification; improved nutrition has a positive influence on CKD. Notably, recent research shows that patients with CKD receiving MNT were able to delay the time to dialysis and improve significant nutritional biomarkers, thereby saving Medicare money and improving patients’ quality of life.7

Technical Elements

Topic Area

  • Chronic Kidney Disease

New Objectives

  • Increase Medicare Part B CKD MNT utilization.
  • Increase the proportion of CKD patients receiving care from a renal dietitian at the first diagnosis of renal disease.
  • Increase the access to care from a renal dietitian for MNT by increasing the number of covered visits per calendar year.

Objective Rationale

  • Healthy People 2020 objectives for CKD may lead to reduction in CKD progression to stage 5 CKD And improve quality of life for people with CKD. This new objective collaborates to help meet the Healthy People 2020 objectives for CKD.
  • The NIH, National Kidney Disease Education Program treatment strategies include delaying progression of the disease, which can be achieved through early nutrition interventions. The program cites it is vital to engage a dietitian knowledgeable in CKD die and nutrition to assess and initiate individualized MNT for patients with CKD as early as possible in the disease state.

Proposed Baseline

  • The Centers for Medicare and Medicaid Services will be able to provide the most recent data to ODPHP for Medicare beneficiaries with CKD utilizing MNT.

Proposed Baseline Unit of Measure

  • % change in number of Medicare Part B CKD MNT units provided annually
  • Number of referrals for MNT

Proposed Target

  • Increase number of referrals for MNT at earlier stages of CKD

Proposed Target Units of Measure

  • % change in number of Medicare Part B CKD MNT units provided annually
  • Units of MNT for CKD (each unit is 15 minutes)

Proposed Target-Setting Method

  • The Academy remains open to discussions with ODPHP regarding the proposed target setting method, but suggests it would be appropriate to consider a 10 percent improvement in utilization.

Expand on Target-setting Justification

  • As noted, research demonstrates the benefit of earlier referral for MNT rather than later referral to slowing the progression to dialysis.8

Proposed Data Sources

  • CMS data as available
  • CROWNWeb, Medicare claims, insurance billings

Conclusion

The Academy sincerely appreciates the ongoing opportunity to offer a proposed new objective for Healthy People 2020’s CKD topic. Please contact either Jeanne Blankenship by telephone at 202-775-8277 ext. 1730 or by email at jblankenship@eatright.org or Pepin Tuma by telephone at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org 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 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation’s food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Friedman EA, Friedman AL. Payment for donor kidneys: Pros and cons. Review. Kidney Int. 2006;69(6):960-2.

3 National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC), Kidney Disease Statistics for the United States. Accessed November 5, 2015.

4 Centers for Medicare & Medicaid Services, Accessed November 2, 2015.

5 United States Renal Data System. 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Accessed October 27, 2015.

6 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.'"

7 De waal D, Heaslip E, Callas P. Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis. J Ren Nutr. 2015.

8 Id.