Academy Comments to CMS re Medicare Program; CY 2018 Quality Payment Program Final Rule with Comment Period

December 22, 2017

Ms. Seema Verma, MPH
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: CMS-5522-FC
P.O. Box 8013
Baltimore, MD 21244-8013

Re: File Code-CMS-5522-FC; Medicare Program; CY 2018 Updates to the Quality Payment Program; CY 2018 Final Rule with Comment Period

Dear Administrator Verma:

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on CMS-5522-FC; CY 2018 Updates to the Quality Payment Program; Final Rule with Comment Period published in the November 16, 2017 issue of the Federal Register. The Academy represents over 98,000 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, hypertension, 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 APMs and associated payment incentives.

RDNs previously participated in the Medicare Part B Physician Quality Reporting System, providing high quality, evidence-based care to patients and delivering substantial cost-savings to the health care system as a whole. And, they are currently participating in some of the CMS Innovation Center's APMs and Advanced APMs. While RDNs are not yet considered "eligible clinicians" (ECs) under the Merit-based Incentive Payment System (MIPS), many are choosing to voluntarily report so as to continue to demonstrate their contributions to improved patient outcomes and wise spending.

The Academy offers specific comments on the following aspects of the Quality Payment Program Year 2 Final Rule with Comment Period:

  1. The Merit-Based Incentive Program System (MIPS)
    1. Low-Volume Threshold
    2. Virtual Groups
  2. General Comments

1. The Merit Based Incentive Program System (MIPS)

a. Low-Volume Threshold

While the Academy appreciates the CMS intent of excluding low-volume providers who are not ready to successfully participate in MIPS so they can avoid financial penalties, we have serious concerns about the significant increase in the MIPS low-volume threshold beginning in performance year 2018. The Academy understands this increase represents an attempt by CMS to be sensitive to the needs of small practices and those in rural and Health Professional Shortage Areas. We also understand that CMS is trying to strike the appropriate balance between the need to account for individual MIPS eligible clinicians and groups who face additional participation burden while not excluding a significant portion of the clinician population. However, we do not agree that the Program Year 2 increases to the MIPS low-volume threshold outlined in the final rule is fair or equitable for those Medicare providers in smaller practices who desire to participate in MIPS or for those Medicare providers not currently recognized as eligible clinicians who will transition into the program in future years, including RDNs.

The Academy recognizes the need for sufficient sample size to be scored on measures, however we have serious concerns that this drastic increase in the low-volume threshold will have the unintended consequence of creating a 2-tier system where large provider practices financially thrive while small practices or those treating smaller numbers of Medicare beneficiaries are driven out of business, decreasing access to care for many Medicare beneficiaries. As noted by CMS, 63% of MIPS eligible clinicians will be excluded from MIPS with this new low-volume threshold beginning in CY 2018. As noted in our comments on the proposed rule, based on data from Medicare Physician and Other Supplier NPI Aggregate Report CY20153, the majority of RDN Medicare providers would be excluded from participation based on the number of Part B beneficiaries they treat. The same holds true for many other Medicare provider types who also make valuable contributions to the goal of achieving better care, smarter spending and healthier people. A value based health care payment program where only some eligible clinicians or groups can participate, succeed in and receive opportunities for positive payment adjustments seems contrary to the CMS goals of supporting smaller practices success and increasing overall participation in the QPP. All practitioners and practices should have a fair opportunity to reap the rewards by way of the positive financial incentives the program offers. In addition to lowering the low volume threshold from the levels noted in the Final Rule, we encourage CMS to consider additional options for defining the low-volume threshold, such as by using a percentage of Medicare charges to total charges and a percentage of Medicare patients to total patients.

We support the CMS belief that the clinicians who do not meet the low volume threshold should, to the extent feasible, have the opportunity to choose whether or not to participate in the MIPS and be subject to MIPS payment adjustments, including the financial incentives offered. Thus, the Academy strongly supports the "Opt-In" concept, as we view it as an opportunity for certain providers who otherwise would be excluded from MIPS to participate and potentially earn positive financial adjustments that they otherwise would not be eligible to receive, including virtual groups that require EC status in order to receive MIPS payment adjustments. The Academy reiterates its previous recommendation that if the Secretary exercises his authority in the future to expand the definition of eligible clinicians, CMS should 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, including, important for success in the program, determination of appropriate volume caps based on provider type. Representatives from the AMA RUC HCPAC could serve as members of such a TEP, as they are knowledgeable about the PFS, PQRS, and APMs.

b. Virtual Groups

The Academy is pleased CMS is offering Virtual Groups as a new third option for participating under MIPS in CY 2018 as a means for interested small groups to meet the threshold required to be considered an EC. The Academy supports this option as it provides an attractive mechanism for providers to participate in MIPS and be eligible for positive payment adjustments not otherwise available to them. If the definition of ECs is expanded in the future to include "other professionals," most RDN Medicare providers would be excluded from MIPS based on not meeting the low-volume threshold. Having an ability to "Opt-In" to MIPS to become a MIPS eligible clinician along with an ability to fully participate as an EC in virtual groups not only provides a solution to this concern, but also meets the agency’s goal of increasing flexibility for participation under MIPS. The Academy believes the virtual group option may help to enhance the viability of small practices, which in turn enhances patient access to necessary, efficacious services, thus helping to meet the goals of better care, smarter spending, and healthier patients. We encourage CMS to monitor the uptake of this option and seek input on barriers to utilizing it as we have concerns that, while it sounds good in theory, there may be practical roadblocks to its success.

2. General Comments

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:

  • Physicians should be either mandated or incentivized to utilize non-physician providers such as RDNs.
  • 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.
  • Non-physician providers, such as RDNs, should not be financially penalized due to a lack of recognition under the MIPS and Advanced APMs. 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 Academies of Sciences, Engineering and Medicine’s Health and Medicine Division (formerly the IOM), most physicians, and the United States Preventive Services Task Force (USPSTF) for 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 urges the Secretary to exercise his authority under Section 1834 (n) (42 USC 1395(m))7 of the Social Security Act to modify the current Part B Medicare MNT benefit to include diet-related chronic diseases as a significant step towards achieving CMS's goals of better care, smarter spending, and healthier people. In doing so, CMS could take advantage of an important opportunity to reduce the regulatory burden on non-physician providers currently unable to provide safe, cost effective care they are qualified to provide. The pool of RDN Medicare providers working in these disease states and conditions would grow, increasing access to clinically effective, low cost services that would be more appropriately incentivized through both pathways of the Quality Payment Program.

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. Currently the "other professionals" noted above (including RDNs) are excluded from the definition of an eligible clinician for the first two 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 rules for Year 1 and Year 2 of the program. 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 and similar opportunities to earn financial incentives offered by the program.

Thank you for your careful consideration of the Academy's comments on the CY 2018 Updates to the Quality Payment Program; CY 2018 Final Rule. 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 312/899-1730 or by email at or Marsha Schofield at 312/899-1762 or by email at with any questions or requests for additional information.


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

Marsha Schofield, MS, RD, LD, FAND
Senior Director, Governance/Nutrition Services Coverage
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 Medicare Physician and Other Supplier NPI Aggregate Report CY2015. Accessed August 6, 2017.

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 (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) modify—
(A) 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
(B) 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.