Comments to CMS Regarding Payment Policies Under 2014 Physician Fee Schedule

September 5, 2013

Marilyn Tavenner
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attn: CMS-1600-P
P.O. Box 8016
Baltimore, MD 21244-8016

Re: File Code-CMS-1600-P; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014; Proposed Rule; (July 19, 2013).

Dear Administrator Tavenner:

The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on CMS1600-P Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 published in the July 19, 2013 Federal Register. The Academy has over 75,000 members including Registered Dietitian Nutritionists1 (RDNs) who independently provide professional services such as medical nutrition therapy (MNT) under Medicare Part B.

MNT provided by RDNs is a widely recognized component of medical guidelines for the prevention and treatment of heart disease, 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 life2. RDNs participate 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.

The Academy offers specific comment on the following proposed rule items:

  1. Using OPPS and ASC Rates in Developing PE RVUs
  2. Geographic Practice Cost Indices (GPCIs)
  3. Medicare Telehealth Services for the Physician Fee Schedule
  4. Complex Chronic Care Management Services
  5. Physician Compare Website
  6. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting System
  7. Physician Value-Based Payment Modifier and the Physician Feedback Reporting Program
  8. Analysis of the Fee Schedule Impact on Specialties

1. Using OPPS and ASC Rates in Developing PE RVUs

CMS proposes to begin capping payment to services performed in the non-facility setting when those payments are greater than what is paid when the same service is performed in either the hospital outpatient or ambulatory surgical center (ASC) facility setting. The Academy supports the comments submitted by the American Medical Association (AMA)/Specialty Society RVS Update Committee (RUC) related to this CMS proposal. The Academy has participated in the AMA RUC process since 2001 and can attest to the rigor and integrity of the process in establishing accurate resource data for each service reviewed by the RUC.

2. Geographic Practice Cost Indices (GPCIs)

In an effort to address the recommendation from the Institute of Medicine in its report, "Geographic Adjustment in Medicare Payment, Phase I: Improving Accuracy,"3 to identify a new source of data to determine the variation in the price of commercial office rent, CMS is considering future use of a proprietary commercial rent data source. While the Academy prefers CMS use a public source of such data for the reasons noted in the proposed rules, we also feel residential rent data does not accurately reflect variations in commercial office rent. Therefore, the Academy supports the use of a proprietary commercial rent data source to calculate the office rent component of the PE GPCI until such time that CMS can identify a suitable public source for this data.

3. Medicare Telehealth Services for the Physician Fee Schedule

CMS is proposing to change their definition of rural HPSAs (Health Professional Shortage Areas) for the purposes of an originating site as those located in rural census tracts as determined by the Office of Rural Health Policy. CMS is also proposing to designate areas as geographically eligible telehealth originating sites annually based on their status as of December 31 of the previous calendar year. The Academy supports both of these proposals as we see them as opportunities to increase access to vital health care services, such as MNT, for beneficiaries for whom traveling long distances for such services poses a challenge. Maintaining eligibility as a telehealth originating site for the entire calendar year minimizes disruptions in beneficiaries' access to services and the operational difficulties noted in CMS' rationale for this proposed change.

CMS is also proposing to add CPT codes 99495 and 99496 to the list of telehealth services for CY2014 (Transition Care Management services). Registered dietitian nutritionists play a critical role in transitions of care for certain beneficiaries for whom nutrition is an essential part of the plan of care. Undernutrition and/or poor diet compliance may contribute to negative outcomes in patients with pneumonia, acute myocardial infarction and heart failure and increase the likelihood of readmission.45 Collaboration among health care professionals, including RDNs, is critical to successful post-acute transitional care plan development and implementation. Adding these codes to the list of telehealth services expands beneficiaries' access to these critical services aimed to improve quality of care and reduce readmissions. Therefore, the Academy supports CMS's proposal to add CPT codes 99495 and 99496 to the list of telehealth services for CY2014.

4. Complex Chronic Care Management Services

CMS proposes to provide payment for complex chronic care management (CCCM) services beginning January 1, 2015. Payment will be made for services provided to patients with two or more complex chronic conditions that are expected to last at least 12 months or until the death of the patient, and that places the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. The Academy supports CMS's decision to pay for CCCM services as they are critical to quality of care, improved outcomes, and cost-savings.

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. Data show that medical nutrition therapy (MNT) provided by an RDN is linked to improved clinical outcomes and reduced costs related to physician time, medication use and hospital admissions for people with obesity, diabetes, and disorders of lipid metabolism, as well as other chronic diseases.67 Any standards developed for CCCM services must recognize the benefits of combinations of primary care and specialty services from multiple clinicians, such as registered dietitian nutritionists, that are necessary in providing quality care for these patients. The Academy urges CMS to develop these standards in a manner that allows payment to all members of the team of physicians and qualified non-physician practitioners located within or outside of a primary care provider's office setting who spend time providing critical care management services. Depending on the individual patient and their needs at a particular point in time, leadership in CCCM services may shift amongst members of the care team, including the registered dietitian nutritionist. RDNs are trained and qualified to perform care management, particularly for patients with complex health needs.

The Academy has been actively involved in the work of the AMA CPT and RUC related to care coordination services. The CPT Editorial Panel has approved new code descriptors to describe CCCM. The Academy urges CMS to align the structure, valuation and understanding of the CCCM services with the work of the AMA CPT Editorial Panel and RUC.

5. Physician Compare Website

CMS proposes to publicly report quality measures for individual eligible providers (reported via claims, EHR or registries) on specific measures as early as CY2015. The Academy supports public reporting of performance rates on quality measures to help consumers choose their healthcare providers. We do have concerns about meaningful use of this data with respect to registered dietitian nutritionist Medicare providers as their patient sample size for PQRS measures often is limited as currently Part B MNT covered services are currently limited to beneficiaries with diabetes and renal disease. Therefore, to make this information meaningful to consumers, the Academy urges CMS to also post the number of patients represented by the data.

6. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting System (PQRS)

While currently RDNs only qualify as eligible providers (EPs) under PQRS, the Academy supports CMS's efforts to align all of its quality improvement programs, reporting systems and quality measures. We believe this alignment will lighten the administrative burden on EPs while harmonizing the various CMS quality programs.

CMS proposes several changes to the PQRS that are of concern to the Academy. First, CMS proposes to change the criteria for satisfactory reporting for individual EPs for the CY2014 incentive (.5%) and the CY2016 reduction (2%) by increasing the number of required measures in claims based reporting from 3 to 9. While the CMS proposal allows for reporting 1-8 measures, this reporting will be subject to the Medicare Applicability Validation (MAV) process. As a specialty provider currently only able to direct bill for MNT services for Medicare beneficiaries with diabetes and renal disease, the number of PQRS measures that an RDN might report is limited. As a result, the agency will routinely incur the administrative burden of the MAV process for the majority of RDN Medicare providers. The Academy urges CMS to retain the current 3 measure reporting requirement for highly specialized Medicare providers with a limited scope of services and therefore limited applicable measures to report on.

CMS is considering eliminating the claims-based reporting mechanism beginning with the reporting period (CY2017) for the CY2019 payment adjustment. While the Academy recognizes the challenges of this reporting mechanism for both providers and CMS as noted in the proposed rules, we urge CMS to retain the claims-based reporting mechanism. As CMS notes, 72% of EPs use this option. In the case of registered dietitian nutritionists, the claims-based reporting mechanism is often the only option available for reporting as they may not yet be linked to EHR systems. Many RDNs providing services to Medicare beneficiaries practice in small single-specialty practices or as part of small multi-provider specialty practices.

CMS proposes a new PQRS reporting option: satisfactory participation in a qualified clinical data registry. The Academy applauds CMS for looking at ways to expand registry reporting options for EPs and sees this new option as a potential opportunity for RDNs to use in the future to participate in PQRS and benchmark their services against similar providers as part of quality improvement processes.

7. Value-Based Payment Modifier (VBM) and Physician Feedback Program

CMS describes the value-based payment modifier as "an important component in revamping how care and services are paid for under the PFS that has the potential to help transform Medicare from a passive payer to an active purchaser of higher quality, more efficient and effective healthcare." The Academy supports efforts aimed at achieving the Triple Aim of health care. MNT provided by RDNs for prevention, wellness and disease management can improve a patient's health and increase productivity and satisfaction levels through decreased doctor visits, fewer hospitalizations and re-admissions, and reduced prescription drug coverage. RDNs provide vital food and nutrition services, while promoting health and well-being to the public. They often operate as solo practitioners. By using their expertise and extensive training, RDNs deliver care that is coordinated and cost-effective in a variety of chronic diseases, such as obesity, hypertension, diabetes, disorders of lipid metabolism, HIV infection, unintended weight loss in older adults and chronic kidney disease.8

The Academy urges CMS, as it continues to evolve the VBM program, to design the system to meet the needs of non-physician EPs and take into account the potentially limited pool of data on which payment decisions might be calculated for highly specialized providers with limited scope of Medicare-eligible services.

8. Analysis of the Fee Schedule Impact on Specialties

CMS routinely omits analysis of the impact of the proposed physician fee schedule changes for the Registered Dietitian Nutritionist specialty; RDNs are not listed in Table 71 "CY 2014 PFS Proposed Rule Estimated Impact on Total Allowed Charges by Specialty." CMS's omission of RDNs in Table 71 makes it difficult for the Academy and RDN Medicare providers to recognize the impact of fee schedule changes on their practices. The Academy urges CMS to annually include the RDN specialty in this table to facilitate an analysis of fee schedule changes on this vital healthcare specialty.

In closing, current Medicare program policies do not allow registered dietitian nutritionists to practice as independent providers for the full scope of MNT services for which RDNs are prepared and which are clinically indicated for Medicare beneficiaries. The Academy supports the IOM's recommendation in its report, Geographic adjustment in Medicare payment: Phase II: Implications for access, quality, and efficiency, that states "the Medicare program should support policies that would allow all qualified practitioners to practice to the full extent of their educational preparation."9 As CMS continues its efforts to achieve access and quality goals, it is important that policies be set that fully leverage the contributions of all members of the health care workforce, including both primary care and specialty care providers.

Thank you for your careful consideration of the Academy's comments on the proposals for the 2014 Medicare Physician Payment Schedule. Please do not hesitate to contact Jeanne Blankenship by phone at 202-775-8277 ext. 6004 or by email at jblankenship@eatright.org or Marsha Schofield at 312-899-4732 ext. 4787 or by email at mschofield@eatright.org with any questions or requests for additional information.

Sincerely,

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

Marsha Schofield, MS, RD, LD
Director, Nutrition Services Coverage Academy of Nutrition and Dietetics
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 Grade 1 data. Academy Evidence Analysis Library, http://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 IOM (Institute of Medicine). 2012. Geographic adjustment in Medicare payment: Phase II: Implications for access, quality, and efficiency. Washington, DC: The National Academies Press.
4 Hoyt RE, Bowling LS. Reducing readmissions for congestive heart failure. Am Fam Physician. Apr 15 2001;63(8):15931598.
5Paterna S, Parrinello G, Cannizzaro S, et al. Medium term effects of different dosage of diuretic, sodium, and fluid administration on neurohormonal and clinical outcome in patients with recently compensated heart failure. Am J Cardiol. Jan 1 2009;103(1):93-102.
6 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project
7 http://www.andevidencelibrary.com/mnt
8 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 2008. http://www.andevidencelibrary.com/mnt
9 IOM (Institute of Medicine). 2012. Geographic adjustment in Medicare payment: Phase II: Implications for access, quality, and efficiency. Washington, DC: The National Academies Press.