Comments CMS Alternative Payment Model Concepts High-Risk Pediatric Populations

April 7, 2017

Seema Verma
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: Request for Information (RFI)
Pediatric Alternative Payment Model Concepts
P.O. Box 8013
Baltimore, MD 21244-8013

Re: CMS Request for Information (RFI) on Alternative Payment Model Concepts

Dear Acting Administrator Verma:

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide input to encourage CMS to proceed with the creation and testing of an innovative payment and service delivery model intended to enhance the quality of care and reduce avoidable expenditures in high risk pediatric populations enrolled in Medicare, Medicaid, and the Children's Health Insurance Program (CHIP).

Representing more than 100,000 registered dietitian nutritionists (RDNs),1 nutrition dietetic technicians, registered (NDTRs), 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 independently provide professional services such as medical nutrition therapy (MNT) under Medicare Part B. RDNs may provide MNT for "high-need, high risk" children via the Early Periodic Screening, Diagnosis and Treatment program when nutrition intervention is determined to be medically necessary per state guidelines, and may also provide MNT for other pediatric populations in states that have added benefits for nutrition counseling.

The Academy strongly supports CMS development of an Integrated Pediatric Health Care and Health-Related Social Service Delivery Model using Alternative Payment Models (APMs) to improve care and outcomes, and decrease avoidable costs in pediatric populations described in the RFI as "high-need, high-risk beneficiaries" covered by Medicaid and CHIP. The Academy appreciates the opportunity to highlight critical gaps in care for the purpose of informing delivery and payment model design, and to provide responses to specific questions proposed in this RFI.

Gaps in Care

A CMS Innovation Model that utilizes multiple and thoughtfully constructed APMs has the potential to facilitate improvements in care that are patient and family-centered, and enable the best practices of team-based care underscored in numerous clinical practice guidelines. APMs, coupled with CMS waivers that afford greater flexibility in the types of care and services that can be provided in both health care settings and in the community, may help remove some barriers to care associated with benefit design and payment related policies. Nutrition is an example of an area where there are significant gaps in care in the pediatric Medicare, Medicaid, and CHIP populations, including "high-need, high-risk" beneficiaries. MNT is an integral part of treatment in achieving functional, cognitive, physical growth, and developmental goals that may prevent more invasive, expensive, and avoidable treatment, comorbid conditions and associated costs.  Medicaid's benefit package does not require coverage for nutrition services. Access to nutrition care may be possible through the Early Periodic Screening, Diagnosis, and Treatment Program, but is dependent on several factors, including state definitions of medically necessary services. The following are some examples of "high-need, high-risk" populations for which there is a wide variation in the nutrition care.

Individuals with Intellectual and Developmental Disabilities and Special Health Care Needs (CYSHCN) are examples of "high-need, high risk" populations with a wide range of conditions including chronic diseases, health-related problems related to prematurity, and congenital defects that require frequent follow up and medical care. "An estimated 11.2 million children, or 15% of all children in the U.S. have special health care needs. Medicaid, CHIP and other public health insurance programs cover nearly half (44%) of children with special health care needs. Public insurance, including Medicaid, is the sole source of coverage for 36% of these children."2

It is the position of the Academy of Nutrition and Dietetics that nutrition services should be provided to children and youth with intellectual and developmental disabilities (IDD) and special health care needs throughout life in a matter that is interdisciplinary, family centered, community based, and culturally competent.3 Children with autism spectrum disorder, cerebral palsy, cystic fibrosis, chromosomal disorders such as Down syndrome, neurological disorders, genetic or inherited metabolic disorders, orofacial cleft, Prader-Willi syndrome, and spina bifida are examples of high risk populations who have significant nutritional risk factors. Some examples include "growth alterations (e.g., failure to thrive, obesity, or growth retardation), metabolic disorders, poor feeding skills, drug-nutrient interactions and sometimes partial or total dependence on enteral or parental nutrition."4 "Nearly seven in ten children with special health care needs have difficulty with bodily functions, such as breathing, swallowing, or chronic pain."5 Therapeutic feeding teams comprised of occupational therapists, speech therapists, and RDNs play a critical role in developmental pediatrics. RDNs work with children with global developmental delay who have conditions including, but not limited to, dysphagia, delayed feeding, failure to thrive, hypotonicity, and conditions that require the use of feeding tubes. They also play an important role in training other interdisciplinary team members, patients, and caregivers in food selection and preparation as part of the intervention plan.

The prevalence of obesity in CYSHCN is almost twice that of the general population.6 Nearly three-quarters of children with special health care needs live in low or middle income families, below 400% of the federal poverty level,7 highlighting the need to screen for and address food insecurity in this population. Individuals with intellectual and developmental disabilities and children with special health care needs require lifelong planning for services and care. Early intervention programs authorized by Part C of the Individuals with Disabilities Education Act enable care from birth through age three and may include nutrition services. There is a significant and real risk of an absence of nutrition care once children enter Medicaid/CHIP, and the medical need still exists. Furthermore, as people with IDD and CYSCHN age and become dually eligible for Medicaid and Medicare, "the combination of cognitive and physical disabilities will significantly increase their medical expenditures; therefore, identifying new strategies emphasizing prevention and early treatment of comorbidities can help maximize future cost benefits."8 An integrated pediatric delivery model design should insure that all CYSHN are referred for and have access to specialized nutrition care based on routine nutrition screening.

Preterm and low-birthweight infants are also examples of "high-need, high-risk" populations at increased risk of immediate life-threatening health problems including respiratory distress, jaundice, anemia, and infection, as well as long-term complications and developmental delays. Long-term complications can include learning and behavioral problems, cerebral palsy, lung problems, and vision and hearing loss.9,10 As a result of these risks, preterm birth and low birth weight are leading causes of infant death and childhood disability. Preterm birth and low birth weight exact a heavy societal toll with the annual economic burden related to preterm birth estimated to exceed $26 billion, including costs for medical care and early intervention as well as lost productivity due to disabling conditions."11 There is a great need for better coordination of services for premature and low birthweight infants who may spend two to three months in the neonatal intensive care unit before being discharged to the home with multiple medical issues and an increased need for nutritional care.

Children with overweight and obesity, with and without comorbid conditions, including, but not limited to, insulin resistance, type 2 diabetes, hypertension, hyperlipidemia, orthopedic conditions such as Slipped Capital Femoral Epiphysis (SCFE) and Blount's disease, depression, disordered eating, non-alcoholic fatty liver disease, (NAFLD) and obstructive sleep apnea are examples of "high-need, high risk" populations where early identification, team-based care, and improved coordination of care could have an impact on the trajectory of outcomes, quality of life, and the long term total cost of care. Currently, childhood obesity is estimated to cost the health care system approximately $14 billion in direct medical costs.12 "Secondary prevention and tertiary prevention/treatment should emphasize sustained family-based, developmentally appropriate approaches that include nutrition education, dietary counseling, parenting skills, behavioral strategies, and physical activity promotion. For youth with obesity and concomitant serious comorbidities, structured dietary approaches and pharmacologic agents should be considered, and weight loss surgery can be considered for adolescents with severe obesity."13 The EPSDT benefit covers all medically necessary services which can include coverage for obesity-related services.14 Coverage for obesity-related services as part of EPSDT is not required. The US Preventive Services Task Force recommends that clinicians screen children age 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status.15 The Affordable Care Act included provisions that promote preventive care including obesity-related services and coverage. The obesity screening and counseling provided in the primary care setting are an important step to reducing rates of obesity in the pediatric population, yet the service may not meet the needs of populations already with obesity and obesity-associated comorbidities, as many practices may not have access to or be utilizing the most qualified and/or cost-effective providers for "intensive, behavioral interventions".

Children living in households experiencing food insecurity are at risk for cognitive, emotional, behavioral, and other health conditions.16,17 A substantial and rapidly growing body of research has demonstrated associations between children's health, development and well-being and measures of food security and food sufficiency. There is a higher prevalence of food insecurity among families with children. Food sufficiency, a condition closely related to food security, has been assessed in several Federal surveys before the development of the food security measures, and the measure was used in much of the earlier research on outcomes of inadequate food access. Findings from several studies on child health and development outcomes associated with food insecurity and food insufficiency found the following conditions to be more likely for children in food-insecure or food-insufficient households than for children in otherwise similar food-secure households:18

  • Poorer health of children, as reported by parents
  • Higher hospitalization rates of young children
  • Iron deficiency anemia in young children
  • Lower physical function in children ages 3-8
  • Poorer psychosocial function and psychosocial development in school age children
  • Higher rates of depressive disorder and suicidal symptoms in adolescents
  • More anxiety and depression in school-age children
  • Higher numbers of chronic health conditions in children

In addition to a high prevalence of food insecurity in households with children, there is an underutilization of health-related social services that may, in part, help address the need.19 There are opportunities to improve health outcomes by increasing health care provider awareness and understanding of the impact of food insecurity and poverty on child health and the effectiveness of federal supplemental nutrition programs such as Women Infants and Children (WIC), on health outcomes. Although RDNs play an important role in coordinating access to health-related social services, the fee-for-service payment model has been a significant barrier to the ability of RDNs to perform such roles in the primary care setting. All healthcare providers could play a pivotal role in health related social services by referring appropriate children and families to programs such as WIC, that are under-utilized by eligible populations. Data from a 2013 United States Department of Agriculture report indicates that although 84.4% of eligible infants participated in WIC in 2012, only 49.8% of children ages one to four participate in WIC.20 Screening for and actively working to address food insecurity is one example of an opportunity to improve health and outcomes through a model that integrates health care and health-related social services.

These examples of populations of "high-need, high-risk" infants, children and adolescents highlight the diversity of conditions for which nutrition and care provided by RDNs is a critical component of treatment, but may not be provided. An integrated model could have a significant impact on patient access to family centered care through tertiary care settings, clinics, homes, schools, and community-based organizations.

Lastly, Medicare and Medicaid policies present barriers to patient access to nutrition care. Virtually all prevalent chronic illnesses have a nutrition component, yet there remain huge gaps in the way our health care system addresses the important role of nutrition in preventing and treating such diseases — particularly in the Medicare program. Under current law, Medicare only covers outpatient medical nutrition therapy services provided by RDNs for beneficiaries with diabetes, chronic renal insufficiency/non-end-stage renal disease (non-dialysis) or post kidney transplant.21 Medicare policy is important beyond its impact on Medicare itself, because states that expand benefits to include nutrition care and private insurers are likely to adopt Medicare's baseline policies as their own. Thus, the Medicare MNT coverage determination has a significant impact on the ability of pediatricians to prevent or manage acute and chronic disease in "high-need, high-risk" pediatric populations.

Response to Questions in RFI

RFI Section I: Integrated Pediatric Health Care and Health-Related Social Services Delivery Model

Question #3: What policies or standards should CMS consider adopting to ensure that children, youth and their families, and providers in rural and underserved communities such as tribal reservations have an opportunity to participate? How might pediatric care delivered at Rural Health Clinics best be included as a part of a new care delivery model for children and youth?

CMS could create a separate track of a pediatric integrated services delivery model that aims to address the unique issue for rural and underserved communities. CMS policies should remove barriers and enable and incentivize the use of telehealth to improve access to care and monitoring by appropriate pediatric specialists, and pay for non-face-to-face interventions with appropriate health-related social services in other parts of a state. Policies regarding telehealth services under the current Medicare program are antiquated and do not adequately address the needs of Medicare patients, providers, and the Medicare program itself. 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 recognized in new delivery and payment models as they offer new opportunities to increase access to care in urban, suburban, and rural areas. Time spent by all qualified health care professionals (both physician and non-physician providers) using such technologies for assessment, treatment, evaluation and monitoring functions needs to be recognized in future payment models. Beneficiaries should be able to receive health care services amenable to telehealth technology in their homes, taking advantage of the wide range of emerging e-health technology. In order for an integrated service delivery model focused on improving care for "high-need, high risk" beneficiaries in rural areas to achieve its goals, the model would also need to recognize and engage non-rural providers who are appropriate specialists, allied health professionals, as well as Centers of Excellence (COE) teams and specialty clinics (e.g., gastroenterology, neurology, pediatric obesity specialists, and feeding clinics). CMS and state Medicaid agencies should engage pediatric specialists and COEs in APMs that also hold specialist provider teams accountable for outcomes.

Question #6: What are some of the obstacles that health care and social services providers as well as payers face when integrating services? How might these obstacles be overcome?

One of the challenges that health care providers face when integrating services is parent and caregiver ability to implement treatment plans. Providing care for "high-risk, high need" children is stressful for families. Providing parents and caregivers with accessible resources and training to improve coping and problem-solving skills that would better enable families to implement treatment plans are examples of health-related social services that would benefit children and families. CMS could consider testing and payment for this type of intervention with families as one strategy to help improve outcomes and decrease avoidable costs as part of an integrated delivery model.

Variable provider access to, and interoperability of, Electronic Health Records remains a significant barrier to ensuring accurate and current patient records and to maintaining critical communication among providers. Complete patient records are not only essential for preventing adverse events and errors, but also for teams to function in order to provide good care. All providers involved in a patient's care must be able to document a patient's condition and communicate with all of the providers involved in team-based care, regardless of the physical location, association of the provider, or proprietary system. It is important to note that allied health professionals were not eligible for EHR incentive programs, which has had an impact on the adoption of EHRS. There are additional barriers for allied health professionals such as RDNs who may not be employed by the practices where their patients receive most of their care, or where organizations do not understand the role of nutrition care in treatment plans.

Variable or lack of payment for services such as nutrition care in the most patient and family-centric settings increases the risk for readmissions into the hospital system in high risk pediatric populations. RDNs provide nutrition care and intervention as members of interdisciplinary teams in the inpatient and outpatient setting and within community-based organizations. A patient and family-centered integrated delivery model that utilizes APMs has the ability to address some gaps in care related to provisions for place of service and covered benefits.

RFI Section III: Integrated Pediatric Service Model Payment and Incentive Arrangements

Question #1: What payment models, such as shared savings arrangements, should CMS consider?

CMS and state Medicaid agencies should consider the use of multiple APMs in order to create the right kind of financial incentives for all health care providers and health-related social service providers to improve care and outcomes. In order to accommodate the range of conditions and specialty care needs in "high-need, high-risk populations," CMS should consider risk-adjusted prospective population based payments for pediatric primary care as well as bundled payments with eligibility for shared savings for team-based specialty care and Centers of Excellence. Fee for service payments with links to quality/outcomes should also be considered if needed to engage important specialists. Furthermore, there needs to be an additional mechanism and financial incentive for all provider types involved in the care to collaborate and coordinate care. The burden of accountability should not fall solely on primary care. Both primary care and specialty providers need to view themselves and their teams as accountable providers for an integrated services delivery model that uses APMs to achieve improvements in care and outcomes in the "high-need, high-risk" pediatric populations covered by Medicaid and CHIP. Payment for coordination of care is essential to an innovation model's ability to improve care and decrease avoidable spending. Coordination of care payments should be commensurate with the expertise and time required to coordinate care in "high-need, high risk" pediatric population, and to enable other providers (e.g. RDN, OT, PT) to perform the role and be paid for the care provided.

An integrated delivery model for high risk pediatric populations presents an opportunity for CMS to simultaneously address important medical risks for preterm and low-birthweight babies through a more holistic and integrated approach. Poor weight gain during pregnancy, previous low-birthweight pregnancy, and chronic health conditions such as diabetes, hypertension, and obesity are examples of medical risk factors for low-birthweight.22 Low birthweight is associated with developing diabetes, heart disease, high blood pressure, and metabolic syndrome, and obesity later in life.23 In a meta-analysis published in 2014, dietary interventions during pregnancy were associated with increased birth weight and length and a reduced incidence of low birthweight. "The provision of nutrition education as well as food or fortified food products to pregnant women, particularly those who are underweight, at nutritional risk, or come from a low-income country, is likely to increase the size of the infant at birth with important health and financial ramifications."24 Integrating nutrition care into a pediatric integrated delivery model that also includes pregnant women could be an effective strategy for reducing the medical risks for preterm and low-birthweight, the leading causes of childhood death and disability. A pediatric model that integrates health care and health related social services should aim to increase participation rates of pregnant women in the WIC program as one strategy to address food insecurity and the risk of low-birthweight. In 2013, 68.4% of eligible pregnant women participated in in the program.25

#5 In addition to Medicaid's mandatory benefits (including supports required under the EPSDT benefit), what other services might be appropriate to incorporate in any new integrated service delivery model?

The Academy strongly recommends that CMS Integrate nutrition services into Pediatric Care Delivery Models and APMs. CMS should factor the cost of delivery of nutrition care into health care payments. "Medicaid's benefit package for children covers traditional medical services like doctor visits, hospitalizations, x-rays, lab tests, and prescription drugs. It also includes behavioral health, dental, hearing, and vision care as well as physical, occupational, and speech therapy and medical equipment and supplies."26 It does not include nutrition care. There is no mandated benefit for nutrition counseling under Medicaid.27 Chronic diseases such as heart disease, diabetes, cancer, and others are the leading causes of death and disability in the United States, and the largest cost drivers for Medicare and Medicaid.28 The prevalence of obesity in CYSHCN is almost twice that of the general population, and there has been a notable increase in hypertension, diabetes mellitus, and obesity in adolescents identified as CYSHCN.29 Poor nutrition is one of the four modifiable health risk behaviors that lead to chronic disease development and severity.30 Providing nutrition care for "high-need, high-risk" populations should be viewed as a strategy for improving the health of two generations.

Thank you for your consideration of the information the Academy has provided to inform CMS's decision to proceed with developing an innovation model in pediatric care. 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 vulnerable populations and meets the needs of all stakeholders. Please do not hesitate to contact Jeanne Blankenship by phone at ext. 312-899-1730 or by email at jblankenship@eatright.org, or Marsha Schofield at 312-899-1762 or mschofield@eatright.org. We look forward to future opportunities to provide input on a draft model and APM proposals.

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


1The 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 lega trademark definitions.

2http://kff.org/medicaid/issue-brief/medicaid-and-children-with-special-health-care-needs/ accessed April 3, 2017.

3"Position of the Academy of Nutrition and Dietetics: Nutrition Services for Individuals with Intellectual and Developmental Disabilities and Special Health Care Needs," Journal of the Academy of Nutrition and Dietetics, 2015; 115-:593-608

4 ibid

5http://kff.org/medicaid/issue-brief/medicaid-and-children-with-special-health-care-needs/ accessed April 3, 2017

6Rimmer JH, Yamaki, K, Lowry BM, Wang E, Vogel LC. Obesity and obesity-related secondary conditions in adolescents with intellectual/developmental disabilities. J Intellectual Disabilities Res. 2010; 54(9); 787-794.

7http://kff.org/medicaid/issue-brief/medicaid-and-children-with-special-health-care-needs/ accessed April 4, 2017

8Rimmer JH, Yamaki, K, Lowry BM, Wang E, Vogel LC. Obesity and obesity-related secondary conditions in adolescents with intellectual/developmental disabilities. J Intellectual Disabilities Res. 2010; 54(9); 787-794.

9March of Dimes. Premature babies. Accessed April 3, 2017

10March of Dimes. Low birth weight. Accessed April 3, 2017

11Behrman R, Stith Butler A, eds. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: National Academies Press; 2007

12http://www.healthycommunitieshealthyfuture.org/learn-the-facts/economic-costs-of-obesity/ accessed April 3, 2017

13"Position of the Academy of Nutrition and Dietetics: Interventions for the Prevention and Treatment of Pediatric Overweight and Obesity." J Acad Nutr and Dietetics. 2013;113:1375-1394.

14https://www.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/reducing-obesity/index.html accessed April 3, 2017.

15 https://www.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/reducing-obesity/index.html

16Council on Community Pediatrics, Committee on Nutrition, "Promoting Food Security for All Children, Pediatrics. 2015: 136:5; e1431-e1438.

17Shankar P, Chung, R, Frank D, "Association of Food Insecurity with Children's Behavioral, Emotional and Academic Outcomes: A Systematic Review." J Dev Behav Pediatr. 2017: 38:153-150.

18Cook J, Frank D, Berkowitz C, Black M, Casey P, Cutts D, Meyers A, Zaldivar N, Skalicky A, Levenson S, Heeren T, and Nord M. Food Insecurity Is Associated with Adverse Health Outcomes among Human Infants and Toddlers. Journal of Nutrition. 2004; 134:1432-38.

19Shankar P, Chung, R, Frank D, "Association of Food Insecurity with Children's Behavioral, Emotional and Academy Outcomes: A Systematic Review." J Dev Behav Pediatr. 2017: 38:153-150.

20https://www.fns.usda.gov/national-and-state-level-estimates-special-supplemental-nutrition-program-women-infants-and-childr-2 accessed April 3, 2017

21Center for Medicare and Medicaid Services National Coverage Determinations Manual Chapter 1, Part 3 (Sections 170 – 190.34) Medical Nutrition Therapy (Rev. 181, 03-27-15)). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_part3.pdf   accessed April 7, 2017

22http://www.marchofdimes.org/baby/low-birthweight.aspx accessed April 4, 2017

23http://www.marchofdimes.org/baby/low-birthweight.aspx accessed April 4, 2017

24Gresham E, Byles J, Bisquera A, and Hure, A. "Effects of dietary interventions on neonatal and infant outcomes: a systematic review and meta-analysis." Am J Clin Nutr 2014;100:1298–321.

25https://www.fns.usda.gov/national-and-state-level-estimates-special-supplemental-nutrition-program-women-infants-and-childr-2  accessed April 3, 2017

26http://kff.org/medicaid/issue-brief/medicaid-and-children-with-special-health-care-needs/ accessed April 4, 2017

27https://www.medicaid.gov/medicaid/benefits/epsdt/index.html accessed April 4, 2017

28https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html accessed April 7, 2017

29Rimmer JH, Yamaki, K, Lowry BM, Wang E, Vogel LC. Obesity and obesity-related secondary conditions in adolescents with intellectual/developmental disabilities. J Intellectual Disabilities Res. 2010; 54(9); 787-794.

30https://www.cdc.gov/chronicdisease/overview/ accessed April 7, 2017