Comments to CMS on Advanced Primary Care

1. Please comment on the above description of PBPs in terms of (a) the impact of the delivery of advanced primary care and (b) primary care practices' readiness to take on such arrangements.

(a) The Academy of Nutrition and Dietetics (the “Academy”) is pleased to provide comments on Advanced Primary Care Model Concepts. The Academy has over 75,000 members including Registered Dietitian Nutritionists (RDNs)1 who independently provide professional services such as medical nutrition therapy (MNT)2 under Medicare Part B, some state Medicaid programs, and all major private payers.

The Academy of Nutrition and Dietetics supports the concept of moving towards population-based payments as we view such payment models as supporting more comprehensive care that recognizes the needs of complex patients. We believe that such an approach to payment has the potential to drive team-based care, which is so critical to achieving the Triple Aim in these populations, and improved access to clinically- and cost-effective services by qualified health care professionals beyond the four walls of a primary care practice. While primary care practices strive to provide the right care to their patients, the realities of an encounter-based payment system unfortunately often provide disincentives for doing so and the current fee-for-service payment model has not kept pace with telehealth technologies.

If such an approach to payment is to be truly effective in driving value and innovation and in creating closer connections between primary care and the medical neighborhood, such models need to be designed to explicitly recognize and facilitate integration of care by non-physician clinical care providers, such as Registered Dietitian Nutritionists (RDNs), beyond the walls of the primary care practice. The model needs to also recognize the use of telehealth services (defined more broadly than current CMS regulations) when it is a cost-effective option proven to enhance clinical outcomes. Research shows that primary care providers do not feel qualified or effective in meeting the nutrition counseling needs of their patients.3 According to the Institute of Medicine, "the registered dietitian is currently the single identifiable group of health-care professionals with standardized education, clinical training, continuing education and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy.4" RDNs are part of the medical neighborhood and such a payment model should be structured in a manner that allows patient access to RDN services and some form of payment to the RDN that is not tied to provision of such services within the walls of the primary care practice. The majority of primary care practices do not have RDNs on site, nor is it necessary for them to be on site to effectively contribute to quality care and patient satisfaction. Whether or not the RDN is on site (so that their services may be billed by the primary care practice), current fee-for-service payments for their services is limited, especially for Medicare beneficiaries. The PBPs as currently defined do not provide a mechanism to provide payment for services that are neither classified as care management services or traditional FFS payment. Thus, PBPs do not support Medical Nutrition Therapy services that are proven to be effective in the management of many chronic diseases.5 The Academy recommends the PBP payment concept be expanded to address payment for a more comprehensive basket of services that is not limited to provision in primary care but that supports a team approach to patient care with the primary care provider as the coordinator of that care.

References

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 Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic re-assessment and intervention. [Academy of Nutrition and Dietetics' Definition of Terms list, accessed 12 March 2015.] The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans.

3 Adams KM, Lindell KC, Kohlmeier M, Zeisel SH. Status of nutrition education in medical schools. Am J Clin Nutr. 2006;83:9441S-944S.

4 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).

5 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 2008.


3. What services should be included in the basket (eg, all primary care Evaluation and Management (E&M) services; primary care E&M services based on certain diagnoses; primary care E&M services plus certain procedures; all service in primary care?). Please provide a rationale for the recommendation.

The Academy of Nutrition and Dietetics recommends the inclusion of Medical Nutrition Therapy services (97802, 97803, 97804) provided by RDNs be included in the basket of care for all patients with chronic medical conditions (ie, complex needs) for which MNT has been shown to improve clinical outcomes.1 MNT provided by RDNs is 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.2

The model should support payment for such services whether they are provided within or outside of the primary care setting. The basket should also include services with a Grade A or B rating by the USPSTF, once again whether provided within the primary care setting or referred by the primary care provider, consistent with the intent of the USPSTF recommendations3. For Medicare beneficiaries, the basket should include all of the preventive services covered under Medicare Part B,4 once again whether or not they are provided within the primary care setting or referred by the primary care provider. If we are to truly achieve comprehensive care for patients with complex needs, closer connections between primary care and other clinical care, and create incentives for innovation in care delivery, the basket of services needs to encompass more than primary care E&M services and services only provided within the four walls of a primary care practice.

References

1 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 2008.

2 Grade 1 data. Academy Evidence Analysis Library, andevidencelibrary.com/mnt. [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 USPSTF Recommendations. Accessed March 12, 2015.

4 www.cms.gov/Medicare/Prevention/PrevntionGenInfo. Accessed March 12, 2015.


8. Practices caring for patients with complex needs – either the practice’s full population or a subpopulation of its patients—could receive additional incentives and resources to deliver enhanced services to these patients, including better integration with social and community-based services, behavioral health, and other health care providers and facilities. What are the best methodologies to identify patients with complex needs (e.g., a claims-based comorbidity measurement; a claims-based utilization measurement; attribution of a population of local beneficiaries without primary care utilization; and/or practice identification through a risk assessment tool and/or clinical intuition)? Please be specific in your responses and provide examples if possible.

The Academy of Nutrition and Dietetics supports the concept of providing additional incentives and resources to deliver enhanced services to patients with complex needs as it would provide improved patient access to critical medical nutrition therapy (MNT) services1 provided by RDNs within the community. We recognize "complex needs" could be defined in many ways in that it could refer to medical needs, psychosocial needs, environmental concerns, high utilizers of the health care system (appropriate or inappropriate), etc. So the first step would be to define "complex needs," followed by determining the best methodologies to identify patients who meet this definition. One way to identify such patients could be based on criteria already established by CMS when defining chronic care management services and complex chronic care management services. Using this definition, identification of patients could be achieved through claims-based utilization measures. An additional or alternative method to define complex patients would be to begin by focusing on the chronic conditions known to be most prevalent in the Medicare population. As noted in CMS' "Chronic Conditions among Medicare Beneficiaries 2012 Chartbook," more than half of Medicare beneficiaries have one or more chronic conditions, such as diabetes, hypertension, high blood cholesterol, heart disease and kidney disease. Efforts to improve quality of care and control spending in these high cost, high volume populations would significantly advance efforts to achieve the Triple Aim. Studies on the patient-centered medical home model of care consistently demonstrate significant clinical and financial improvements with care coordination efforts focused on such populations.2,3)

Alternatively, the Academy recommends practice-based identification using validated risk assessment tools as well as national clinical practice guidelines for specific chronic conditions.4 The latter should include hypertension, high blood cholesterol, heart disease, heart failure, obesity, undernutrition and unintended weight loss, metabolic syndrome/pre-diabetes, celiac disease, HIV/AIDS, and COPD.5

One validated risk assessment tool that can be used in primary care to identify the need for RDN services is the MNA-SF.6

Within any of these methodologies, severity-adjustments should be made based on medical and psychosocial/environmental factors that may impact complexity of care and care coordination.

References

1 Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic re-assessment and intervention. [Academy of Nutrition and Dietetics' Definition of Terms list, accessed 12 March 2015.] The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans.

2 Proof in Practice: A Compilation of Patient Centered Medical Home Pilot and Demonstration Projects, Patient-Centered Primary Care Collaborative, 2009.

3 Higgins S, Chawla R, Colombo C, Snyder R, Nigam S. Medical homes and cost and utilization among high-risk patients. Am J Manag Care. 2014:20(3):e61-e71.

4 See, e.g., Clinical Practice Guidelines for Chronic Kidney Diseases: Evaluation, Classification, and Stratification, National Kidney Foundation. Accessed 17 December 2012.
See also, Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2013; Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 ("The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular (CV) diseases, improve the management of people who have these diseases through professional education and research, and develop guidelines, standards and policies that promote optimal patient care and CV health.").

5 Gradwell E, Raman PR. The Academy of Nutrition and Dietetics National Coverage Determination Formal Request. J Acad Nutr Diet. 2012:112:149-176.

6 Academy of Nutrition and Dietetics Evidence Analysis Library. Nutrition Screening Tools 2009-2010. Accessed March 13, 2015.


b. Should the payment structure discussed in questions 1-7 above differ for these patients? If so, how?

The Academy of Nutrition and Dietetics supports component one1 of the proposed PBPs as one mechanism to support better integration with social and community-based services, behavioral health, and other health care providers and facilities. Many health care professionals, based on education, training and scope of practice, are qualified to provide care management services. For example, the scope of practice for registered dietitian nutritionists (RDNs) includes several care management functions.1 The Pennsylvania Chronic Care Initiative,2 Family Health Teams in Canada,3 and Community Care of North Carolina4 are all examples of models of care in which RDNs provide care management services to patients.

However, in order to achieve the ultimate goal of improving the care of complex patients, the payment structure needs to move beyond the primary care practice to ensure access to and appropriate utilization of these community-based services and other health care providers. In the case of medical nutrition therapy services provided by RDNs, current fee-for-service payments for such services is limited, especially for Medicare beneficiaries, despite evidence to support the effectiveness of MNT services for a wide variety of medical conditions and many chronic diseases.5 Unfortunately, patients with complex needs who could benefit from such services often do not receive the necessary referrals from the primary care providers or follow-through with scheduling these referrals due to significant gaps in coverage. The Academy therefore recommends that services provided by other health care providers deemed medically necessary as part of the plan of care for patients identified as having complex needs by the primary care practice and referred by the practice, be eligible for payment. Such a payment does not necessarily need to be an encounter-based payment, but could be a Per-Patient-Per-Month payment with patients assigned/attributed to these health care providers. An accountability piece should be built into the payment model so that both the primary care practice and the other health care provider are responsible for specific quality metrics relevant to the patient’s condition(s). A value-based payment methodology could be applied to these patients in a manner that does not require the primary care practice to become a "payer" with regard to other health care providers within the medical neighborhood. The model needs to also recognize the use of telehealth services (defined more broadly than current CMS regulations) as a mechanism to enhance access to care when it is a cost-effective option proven to enhance clinical outcomes.

References

1 Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. J Acad Nutr Diet. 2013:113(6), S17-S28.

2 Wang QC, Chawla R, Colombo CM, Snyder RL, Nigam S. Patient-centered medical home impact on health plan members with diabetes. J Public Health Management Practice. 2014;00(00):1-9.

3 Rosser WW, Colwill JM, Kasperski J, Wilson L. Progress of Ontario's family health team model: A patient-centered medical home. Ann Fam Med March/April 2011;9:165-171

4 Community Care of North Carolina – Program Impact. Accessed June 20, 2014.

5 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 2008.


d. What performance metrics are most appropriate and meaningful to assess the quality of care for these patients?

10. What transformative changes to HIT – including electronic health records and other tools – would allow primary care practices to use data for quality measurement and quality improvement, effectively manage the volume and priority of clinical data, coordinate care across the medical neighborhood, engage patients, and manage population health through team-based care (e.g., transitioning from an encounter-based to a patient-based framework for organizing data; using interoperable electronic care plans; having robust care management tools)?

The emergence and rapid growth of health information systems, telehealth and mobile technologies designed to improve the health of individuals, enhance patient engagement and lower costs should be recognized in this model as it offers 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 the payment model and should extend beyond the current restrictions of Medicare coverage guidelines. Where possible, patients and their caregivers should have access to their health information in electronic format, where they can provide insight and oversight to the documentation of their care.

Health care providers continue to struggle with achieving the universal inter-operability of electronic health records (EHR) that is critical to the success of coordinated health care delivery across the spectrum of providers and continuum of care. The success of an advanced primary care model striving to coordinate care across the medical neighborhood and manage population health through team-based care relies on communication and coordination of care across physician and non-physician office practices, laboratory and imaging centers, home health agencies, durable medical equipment suppliers, pharmacies, and other community agencies/resources. Stimulus funds and incentive payments for adoption of electronic health records have been limited to physicians, creating challenges for other essential players on the health care team when it comes to timely communication and access to critical information needed to develop, implement and monitor a patient’s plan of care. Even when providers have access to an electronic health record, interoperability of these systems is not yet at the level needed for optimal support of such a model.

The Academy has worked extensively to promote interoperability across all areas of care. The Academy remains active in advocating for nutrition inclusion in HIT regulations, standards and consistent use of like terminologies which have evolved as a result of the Health Information for Economic and Clinical Health Act.1 As more practices implement and effectively use the HIT standards and guidance from each iterative stage of the EHR financial incentive program, patient progress can be better evaluated. We have mapped the Academy's Nutrition Care Process Terminology with mandated clinical coding systems to assure consistent, appropriate use of clinical terms which are nutrition focused. The Academy has participated in the development of Health Level Seven (HL7) Allergy and Intolerances standard, the creation of a Nutrition/Diet Order draft standard and are presently replicating much of this content into the more easily implemented- Fast Healthcare Interoperability Resource (FHIR) standard. The inclusion of a "Nutrition Section" in the second release of the Consolidated Clinical Document Architecture (C-CDA) should also provide a robust method of sharing nutrition care between professionals and the patient/caregivers. We recommend a model which supports the use of consistent HIT standards to exchange critical nutrition data for patients, professionals and health care providers.

References

1 Index for excerpts of the American Recovery and Reinvestment Act of 2009 (ARRA) Provisions