Comments re Accelerating and Aligning Population Based Payment Models

March 7, 2016

Dana Gelb Safran, ScD and Glen Steele, Jr. MD PhD
Co-chairs, Population-Based Payment Work Group
Health Care Payment Learning & Action Network (LAN)

Re: Comments Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking Draft White Paper released February 8, 2016

Dear Drs. Safran and Steele,

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on the Health Care Payment Learning and Action Network's (LAN) Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking White Paper. The Academy has over 75,000 members, including Registered Dietitian Nutritionists1 (RDNs). Every day our members work with individuals from all walks of life – from birth through old age - providing professional services, such as medical nutrition therapy (MNT). The Social Security Act broadly defines MNT as "nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a registered dietitian or nutrition professional pursuant to a referral by a physician."2

The Academy supports the LAN's objective "to encourage alignment between and within the public and private sectors as the health care system moves away from traditional fee-for-service payments" and "move concertedly towards Alternative Payment Models (APMs) in Categories 3 and 4," to population-based payments.3 The Academy views the adoption of APMs not only as essential to the health care system's ability to reduce unnecessary and avoidable health care costs and improve care, but also as an opportunity to address important gaps in quality care associated with the fee-for-service model and inadequate health benefits design.

The Academy appreciates the second opportunity to provide comment on a work product of the LAN; recommendations for the Alternative Payment Model (APM) Framework White Paper were submitted in November of 2015. The Academy supports the overall purpose, key principles, and general recommendations presented in the Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking Draft White Paper (the "White Paper"). The recommendations in the White Paper refer to APMs in Categories 3 and 4, in which providers accept accountability for the full continuum of care.4 We believe additional language and direction may help stakeholders be more accurate in estimating the Total Cost of Care (TCOC) and in setting financial benchmarks.

Defining the Total Cost of Care

Please refer to The Total Cost of Care language in the "Definitions" section on page 4 of the White Paper. The TCOC definition contains language stating that the scope of the TCOC "should 'carve in' behavioral health care and pharmaceutical costs, because these are critical areas of care for patients and have a significant impact on national health expenditures and patient outcomes." The Academy concurs that this is an important recommendation that will assist organizations in efforts to estimate the TCOC.  The Academy would like to recommend that the Work Group consider additional language to this section that will help organizations estimate the TCOC, design successful APMs, and simultaneously improve patient-centered care.

Organizations should be encouraged to not only look at historical cost benchmarks, but to also estimate costs based on providing patient-centered and cost-effective care. Another way of stating this might be to recommend that organizations identify important gaps in care associated with current delivery and payment models, and estimate the cost of providing that care in APMs that will help facilitate improved health outcomes and reduce the total cost of care. MNT provided by RDNs is an example of a widely recognized component of medical guidelines for the prevention and treatment of heart disease, diabetes, renal disease, obesity, cancers, 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.5 MNT is an example of a cost-effective service unlikely to be identified in historical claims and encounter data. Stakeholders could consider additional sources of information such as standards of care and clinical guidelines to inform the understanding of evidence-based care and to estimate the cost of delivering those services.

Secondly, the Academy recommends that the LAN provide additional clarification on language included in the TCOC definition. The section states, "In addition, it is essential that for the purposes of setting the benchmark, TCOC calculations include only services covered under the insurance plan, because it would be unreasonable for benchmarks to reflect payments for services that are not covered (e.g. dental services)." It may be important for the Work Group to clarify whether this language is referring to services that fall outside of the category of medical benefits (e.g. most dental services), or if this statement includes services that fall under the category of medical benefits, yet are not covered benefits under some insurance plans.

If the statement is referring to any services that fall into the category of medical benefits, yet are not covered benefits, the statement diminishes provider flexibility and ability to deliver patient-centered and perhaps more cost-effective care in a population-based payment model, and appears to be in conflict with the importance of provider flexibility highlighted in the Alternative Payment Model Framework White Paper.6 This statement weakens the incentive for provider organizations and providers to change behavior, thereby reducing the potential for improvements in patient-centered care, delivery of services, and reductions in the TCOC. Notwithstanding its demonstrated benefit and effectiveness, Medicare only covers MNT for beneficiaries with diabetes, chronic renal insufficiency/non end-stage renal disease (non-dialysis) or post kidney transplant. Medicare beneficiaries with cancer, or those whose orthopedic surgery outcomes could improve with weight loss, do not have a benefit for MNT. Benefits and coverage for MNT vary considerably with private payers.

There is a strong need for health benefit redesign that mirrors what is required to improve health care delivery and decrease costs; the inclusion of such a statement in the TCOC section only hampers providers' efforts to provide patient centered care that is evidence-based and "payer agnostic,"7 while decreasing the impetus for purchasers and payers to engage in benefit reform. In summary, the Academy recommends that the Work Group either further define or explain the services that should not be considered in setting financial benchmarks, modify the language, or remove the statement from the TCOC sub-heading altogether to prevent APMs in categories 3 and 4 of having unintended consequences, which could include the withholding of important care.

The Work Group believes that TCOC should "be measured consistently within market segments, be attributed to provider organizations that take accountability as opposed to geographic regions; and allow for maximum flexibility in how provider organizations spend money, including investments in social services and other interventions that address social determinants of disease (and in fact may not have been used to set the benchmark)." We support the Work Group's recommendations in this section8 and recommend that the Work Group also include a fourth statement about the need for maximum flexibility in how provider organizations spend money, including future spending on evidence-based treatments (e.g. Medical Nutrition Therapy/MNT) that are unlikely to be been identified in historical claims and encounter data, given a dearth of claims for effective, but uncovered and/or underutilized services.

The White Paper would thus be strengthened with the addition of language that will assist organizations in distinguishing between services that address social determinants of disease at various levels of prevention, for example, and services that are a component of treatment and management of disease that also may not have been used to inform financial benchmarks.  We recognize that there are many patient-centered and cost-effective services not delivered in the existing fee-for-service model, and suggest that the inclusion of the suggested forward-thinking language in the TCOC section would strengthen the ability of Alternative Payment Models to yield not only reductions in cost, but also facilitate improvements in health care delivery and outcomes. Collectively, these recommendations to the Work Group are intended to help organizations get "closer to the mark" when setting financial benchmarks and in estimating the TCOC, without sacrificing the delivery of important cost effective services simply because they were not included in the initial financial analyses.

As mentioned in previous comments on the APM framework submitted to the LAN in November of 2015, the Academy is currently developing a framework for the payment of cost-effective nutrition services in APMs, and we welcome the opportunity to share our resource with the LAN and its stakeholders upon its completion. The framework may be of interest to organizations designing population-based payments for the continuum of care for chronic disease, as well as episode-based payments for cancer, joint replacement surgery and maternity care.

Thank you for the opportunity to provide comments on the white paper regarding financial benchmarking. Please do not hesitate to contact Jeanne Blankenship by phone at 202/775-8277, ext. 6004 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 Initiatives and Advocacy
Academy of Nutrition and Dietetics

Marsha Schofield, MS, RD, LD, FAND
Senior Director, Governance
Academy of Nutrition and Dietetics

1 The Academy 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 42 U.S.C. 1395x(vv)(1).

3 Alternative Payment Model Framework Final White Paper, published January 12, 2016, Accessed February 19, 2016

4 "Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking Draft White Paper" Version date 2 February 2016, page 2.

5 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."

6 Alternative Payment Model Framework Final White Paper, published January 12, 2016, pages 1, 5, and 10.  Accessed February 19, 2016.

7 Hochman, M, Chen A, Serota M, "Payer AgnosticismThe New England Journal of Medicine,  2013; 369:502-503. Accessed March 6, 2016.

8 "Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking Draft White Paper" Version date 2 February 2016, page 5.