Patient Centered Nutrition Services Payment Model:

An Approach to Incentivizing the Routine Provision of High Quality Nutrition Services

Accountable Payment Models Task Force of the

Academy of Nutrition and Dietetics

May 2016 Task Force Members: Michael Fleming, MD, FAAFP Harlivleen Gill, MBA, RD, LD Ingrid Knight, RDN, LD Beth Ogata, MS, CD Dee Pratt, RDN, LDN Becky Sulik, RD, CDE, LD Jane V. White, PhD, RD, FAND, LDN (chair) Staff: Michelle Kuppich, RD Pepin Andrew Tuma, Esq. Marsha Schofield, MS, RD, LD, FAND

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Executive Summary Patient Centered Nutrition Services Payment Model Relevance of the Provision of Nutrition Services to Health Promotion, Disease Prevention and Treatment A scientifically sound approach to the latest food and nutrition guidelines recommended to promote health and/or ameliorate disease is needed. The evidence-based knowledge, counseling, and coaching competencies offered by Registered Dietitian Nutritionists (RDNs) are vital to improving the health and well-being of the American public and to reducing short and long-term health care costs. Time and professional expertise are required to get to know and understand the meaning of food and eating in individuals’ lives and to work with them as they adopt more healthful food intakes, food-related behaviors, and activity patterns that will lead to the maintenance of a healthier lifestyle. RDNs are nutrition experts, but also have extensive training and expertise in other areas of health care delivery as shown here. Making the Case for High Quality Nutrition Services Provision and Payment To achieve the goals of the Triple Aim1 and the Centers for Medicare and Medicaid Services “Better Care, Smarter Spending, Healthier People” 2 goals set forth in 2015, preventive and therapeutic nutrition services must be provided in a timely and cost effective manner to those diagnosed with diet-related diseases/conditions that require lifestyle modifications to optimize and maintain health. This document was developed to provide information that will assist payers in recognizing and overcoming barriers to cost-effective nutrition care associated with the fee-for-service model, and in understanding the nutrition interventions throughout the continuum of care and lifespan. It utilizes a construct of alternative payment models (APMs) to facilitate the delivery of evidence-based nutrition care by cost-effective providers, Registered Dietitian Nutritionists (RDNs), to improve patient outcomes and contribute to a decrease in the total cost of care. An Academy of Nutrition and Dietetics Task Force was established in March of 2015 to develop guiding principles for the design, development and alignment of Academy proposals consistent with nationally-developed Alternative Payment Models (APMs) to ensure the delivery of high-quality, cost-effective, comprehensive nutrition services provided by Registered

1 Institute for Healthcare Improvement http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx. Accessed March 21, 2016. 2 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-2.html Accessed Sept 27, 2016.

• Population Management • Screening/Assessment • Prevention o Lifestyle Modification Food/Nutrients Activity Smoking Alcohol/Drugs

• Care Plan Development o Nutrition Education o Nutrition Coaching o Nutrition Counseling o Medical Nutrition Therapy o Ongoing Monitoring/Care

Plan Revision • Acute/Chronic Care

Coordination • Transitional Care

Coordination • Health Outcomes

Collection/Benchmarking • Continuous Quality

Improvement/Patient Satisfaction Monitoring

• Food-Nutrient-Drug Interaction o Monitoring o Intervention

• Medications Reduction/Management

• Admission/Readmissions Reduction

Typical Services Provided By RDNs

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Dietitian Nutritionists and Nutrition and Dietetic Technicians, Registered (NDTRs). Utilizing diabetes mellitus as an example, the framework presented in this document cites a variety of “frequently described” payment models and shows how the incorporation of nutrition services can improve population health and health care provision in both the public and private sector. While current fee-for-service model limits the delivery of nutrition services by diagnosis, site of service, and length of service, this document provides examples of nutrition services delivery across a spectrum of payment models, sites of service and lengths of service best suited to address the preventive and/or therapeutic needs of the patient across the continuum of care.

Demonstration of Inclusion of Cost-Effective Nutrition Care in APMs

Costs: Coronary heart disease, congestive heart failure, hemiplegia, and amputation were each associated with 70% to 150% higher costs. Costs were approximately 300% higher for end-stage renal disease treated with dialysis and approximately 500% higher for end-stage renal disease with kidney transplantation. Rui Li PhD, et al. Medical costs associated with type 2 diabetes complications and comorbidities. Am J Manag Care. 2013; 19(5):421–430 *Examples of services provided by RDNs in diabetes may include, although not limited to the following: individual or group MNT, Intensive Lifestyle Interventions, Shared Medical Visits, Group Nutrition Visits, Diabetes Self-Management & Education, Diabetes Self-Management & Training, obesity management for the treatment of type 2 diabetes, case management, smoking cessation, Continuous Glucose Monitoring training delivered in the most cost-effective settings Benefits to stakeholders, when nutrition services provided by RDNs are incorporated into routine care and factored into the total cost of care, include, but are not limited to:

• Improved clinical outcomes and reduced costs, medication use and/or length of stay for people with obesity, diabetes and disorders of lipid metabolism, as well as other chronic diseases 3 4

3 Academy of Nutrition and Dietetics. Evidence Analysis Library. http://www.andeal.org/topic.cfm?menu=5284&cat=4085 Published 2009. Accessed Sept. 13, 2016. 4 Academy of Nutrition and Dietetics. Evidence Analysis Library. http://www.andeal.org/dm Published 2015. Accessed Sept. 13 2016.

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• Reductions in glycemia at all stages of diabetes, reduced admissions, and lower average monthly health care costs 5 6 7 8

• Improvement in vital signs, biochemical and anthropometric parameters including blood pressure, waist circumference, and lipids9 10

• Compliance with and more cost-effective delivery of the counseling services required under the Affordable Care Act 11 12 13 14

• Cost savings as a result of lower average health plan costs, fewer hospital admissions and lower medicals costs from RDN-led lifestyle case management programs in comparison with usual care in persons with Type 2 diabetes and obesity 15

• Realize “value” when RDNs are utilized by stakeholders to inform population management strategies and identify the most cost-effective interventions from prevention to complex care

Documentation of the efficacy of evidence-based nutrition interventions provided by RDNs and the scenarios contained in this document offer clear examples of the myriad of ways in which RDN services can be readily incorporated into evolving delivery and payment models to achieve the goals of better care, smarter spending, and healthier people. RDNs, as valued members of the health care team, are capable of and ready to embrace alternate payment methodologies and be held accountable, along with other health care professionals, for the services they provide. We look forward to working with various stakeholders to adapt and implement the Patient Centered Nutrition Services Payment Model in various health care delivery sites and patient populations, including but not limited to the population at risk for and with diabetes. 5 UK Prospective Diabetes Study (UKPDS) 7. Response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients. Metabolism. 1990; 39:905-912. 6 Coppell/LOADD study, cited by Franz M, Boucher J, Evert A. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014: 7; 65-72 7 Johnson R. The Lewin Group. What does it tell us, and why does it matter? J Am Diet Assoc. 1999; 99: 426-427. 8 Gurvey J. Examining health care costs among MANNA clients and a control group. Journal of Primary Care and Community Health. 2014; 4(4):311-317. 9 Academy of Nutrition and Dietetics. Evidence Analysis Library. http://www.andeal.org/topic.cfm?menu=5284&cat=5233 Published 2015. Accessed Sept. 8, 2016. 10 Academy of Nutrition and Dietetics. Evidence Analysis Library. www.andeal.org/dm Published 2015. Accessed Sept. 13, 2016. 11 http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/ 12 The Academy of Nutrition and Dietetics Evidence Analysis Library MNT Effectiveness project: www.andeal.org/mnt Published 2015. Accessed Sept. 13, 2016 13 Bradly, Donald MD et al. The incremental value of medical nutrition therapy in weight management. Managed Care. January 2013; 41-45. 14 Wolf AM, Siadaty M, Yaeger B, et al. Effects of lifestyle intervention on health care costs: improving control with activity and nutrition (ICAN). J Am Diet Assoc. 2007; 107(8):1365-73. 15 ibid

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Table of Contents Page

I. Rationale for the Inclusion and Payment for Nutrition Services Provision .................. 6 II. Benefits to Stakeholders ............................................................................................... 6 III. Typical Services Provided by Registered Dietitian Nutritionists ................................... 8 IV. Current Nutrition Services Coverage and the Need for Payment Reform ................... 8 V. Barriers to Nutrition Care and Access to RDN Services .............................................. 10 VI. Population Management and Gaps in Cost Effective Nutritional Care ...................... 12 VII. Assumptions for Evidence-Based Nutrition Interventions

Provided by RDNs in Diabetes Care ............................................................................ 14 VIII. Framework for the Integration of and Payment for RDN Services by

Alternative Payment Model ……………………………………………………………………………………17 a. Fee-for-Service Payments ..................................................................................... 18 b. Bundled and Episode-Based Payments ................................................................ 21 c. Population Based Payments ................................................................................. 22

IX. Summary ..................................................................................................................... 23 X. Additional Resources .................................................................................................. 24 XI. Appendix: Levels of Routine and Specialized Nutrition Services Provision

within the Diabetes Mellitus Disease Continuum ...................................................... 25

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Patient Centered Nutrition Services Payment Model Rationale for the Inclusion of and Payment for Nutrition Services Provision The Patient-Centered Nutrition Services Payment Model (PCNSPM) is a framework to enable the delivery and payment of cost-effective nutrition services in Alternative Payment Models (APMs).16 It was developed by the Academy of Nutrition and Dietetics (the “Academy”) to assist payers and provider organizations in decreasing the total cost of care through the delivery of evidence-based, patient-centered nutrition care by leveraging the general and specialized services of registered dietitian nutritionists (RD/RDN)17. It is intended to improve provider team and patient access to cost-effective services and providers and promote appropriate utilization of health care services while enhancing the nature and flexibility of nutrition services delivery, in return for improved outcomes and accountability. The model uses diabetes mellitus (DM) to illustrate how payers can save money by choosing to incentivize and pay for cost-effective services provided by RDNs in the management and prevention of chronic disease. Virtually all prevalent chronic illnesses and many acute conditions have nutrition components, yet there remain huge gaps in the way the health care system addresses the important role of nutrition in disease prevention and treatment. Cancer, cardiovascular disease, obesity-associated conditions, gastrointestinal disorders, and malnutrition are just some examples where the payment for the delivery of nutrition care would lead to improvements in health outcomes and a decrease in the total cost of care. Designing health care payment models that incentivize the delivery and factor in the cost of evidence-based nutrition care, and other services provided by RDNs, is an important step in providing flexibility for care to be delivered in cost-effective settings by cost-effective providers. APMs also have the potential to address gaps in care that are at least partly associated with a fee-for-service payment model. Benefits to Stakeholders The PCNSPM will benefit healthcare stakeholders in the following ways:

• Identify nutrition care and Medical Nutrition Therapy (MNT)18 integral to achieving optimal outcomes throughout the continuum of diabetes care

• Demonstrate how to use MNT in the continuum of diabetes care to receive a return on investment • Avoid paying for unnecessary and/or more expensive care by addressing gaps in nutrition care

16 Health Care Payment Learning & Action Network. Alternative payment model framework final white paper. https://hcp-lan.org/groups/apm-fpt/apm-framework/ Published January 12, 2016. Accessed February 19, 2016 17 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. 18 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 March 3, 2016.] Academy’s definition of medical nutrition therapy is broader than the MNT definition established by Medicare Part B and other health plans. In addition, the Academy definition may differ from the MNT definition included in state licensure laws. The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans.

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• Identify and overcome barriers to the use of cost effective nutrition care associated with the fee-for-service model

• Use RDNs to deliver other services within the RDN scope of practice (e.g., case management, self-management) in a cost-effective way

• Create networks of cost-effective providers able to provide care outlined in standards of medical care and clinical practice guidelines19 20

• Promote enrollee access to and utilization of cost-effective nutrition services providers • Design benefits that align with goals of delivering cost-effective care, including nutrition care and

services needed to optimize and sustain health • Construct APMs that account for and incentivize the inclusion of cost-effective nutrition

interventions with cost-effective providers • Address gaps in care and minimize costs associated with a diagnosis of diabetes, especially among

the sub-populations of the 86 million with prediabetes at high risk for developing diabetes • Reduce future health care costs through improved nutrition status and the prevention/delay in the

onset of chronic diet-related diseases/conditions and their associated co-morbidities • Recognize and facilitate provision of important nutrition interventions throughout the continuum

of diabetes care and lifespan (see Appendix)

19 American Diabetes Association standards of medical care in diabetes 2016. The Journal of Applied Clinical Research and Education, Diabetes Care. 2016;39(suppl 1):1-119. 20 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. http://circ.ahajournals.org/search?fulltext=obesity+treatment+guidelines&submit=yes&x=11&y=10 Accessed March 3, 2016.

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Current Nutrition Services Coverage and the Need for Payment Reform Eighty-six percent of health care spending in 2010 was associated with one or more chronic health conditions. There is widespread agreement that health risk behaviors – poor nutrition, excessive alcohol consumption, inactivity, tobacco use – are major contributors to the majority of illness, suffering, and premature death associated with chronic diseases and conditions and their associated health care costs.21 In the case of diabetes, the cost of caring for people with diabetes is substantial and is associated with suboptimal glycemic control, abnormal kidney function, and proteinuria.22 The 2016 Standards of Medical Care in Diabetes Education also identify nutrition, physical activity, and smoking cessation in the Foundations of Care.23 Despite the recognition of the importance of providing cost-effective care and

21 The Centers for Disease Control and Prevention. Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/chronicdisease/overview/. Reviewed August 26, 2015. Updated February 23, 2016. 22 McBrien K, et al. Health care costs in people with diabetes and their association with glycemic control and kidney function. Diabetes Care. 2013;36:1172-1180.

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interventions that will ultimately address important determinants of health, there remain challenges to delivering such care. Some examples include benefit design that is not in alignment with the goals of evolving health care delivery models, coverage limitations, medical policies and administrative processes required to ensure patient access and provider payment for services rendered. Under current law, Medicare only covers outpatient MNT services provided by RDNs for beneficiaries with diabetes, chronic renal insufficiency/non-end-stage renal disease (non-dialysis) or post kidney transplant. 24 Benefits, coverage, and medical policies and/or clinical guidelines for nutrition counseling and MNT vary significantly with private payers. Yet health care spending for obesity 25 and its comorbidities including diabetes, 26 osteoarthritis, 27 certain cancers, 28 heart disease and stroke, 29 and alcohol abuse 30 equal or exceed these costs. “Only about half of persons with diabetes receive diabetes education and fewer see a registered dietitian/nutritionist. One study of over 18,000 people with diabetes revealed that only 9.1% had at least one nutrition visit within a 9-year period of time.” 31 The National Standards for DSME/T (Diabetes Self-Management Education/Training) list “incorporating nutritional management into lifestyle” as one of nine core topics in a comprehensive program. Some DSME/T programs include MNT services delivered by an RDN, whereas other programs provide basic nutrition guidance and rely on referrals for MNT.32 The provision of early preventive and therapeutic nutrition services could significantly reduce the disease burden of the American public and lower associated health care costs.33 RDNs are nutrition experts, but also have extensive training and expertise in other areas of health care delivery and public/community health system dynamic models. Care coordination can be provided by a wide variety of health care professionals. RDNs possess broad competencies that can be leveraged in both primary and specialty care, and many are already working in such roles within Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs). 34 Concerns about provider shortages should lead payer and

23 American Diabetes Association standards of medical care in diabetes 2016. The Journal of Applied Clinical Research and Education, Diabetes Care. 2016;39(Suppl 1):1-119. 24 National Coverage Determination (NCD) for Medical Nutrition Therapy (180.1) https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=252&ncdver=1&NCAId=53&NcaName=Medical+Nutrition+Therapy+Benefit+for+Diabetes+%2526+ESRD&IsPopup=y&bc=AAAAAAAAIAAA& accessed March 2 2016 25 Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer- and service-specific estimates. Health Aff. 2009; 28(5):w822-31. http://content.healthaffairs.org/content/28/5/w822.full.htmlhttp://www.cdc.gov/Other/disclaimer.html. Accessed June 20, 2015. 26 American Diabetes Association. The Cost of Diabetes. http://www.diabetes.org/advocate/resources/cost-of-diabetes.html. Accessed March 3, 2016. 27 Centers for Disease Control and Prevention. Arthritis Cost Statistics. http://www.cdc.gov/chronicdisease/overview/index.htm. Accessed March 2, 2016. 28 National Cancer Institute. Cancer Prevalence and Cost of Care Projections. http://costprojections.cancer.gov/. Accessed June 20, 2015. 29 American Heart Association. Circulation. 2014; 129(3):e28-292. http://circ.ahajournals.org/content/early/2013/12/18/01.cir.0000441139.02102.80.full.pdf. [PDF - 15.97 MB] Accessed June 20, 2015. 30 Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic costs of excessive alcohol consumption in the US, 2006. Am J Prev Med. 2011; 41(5):516-24. http://www.sciencedirect.com/science/article/pii/S0749379711005381. Accessed June 20, 2015. 31 Franz M, Boucher J, Evert A. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2014;7:65-72. 32 Powers MA. Diabetes Self-Management Education and Support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Journal of the Academy of Nutrition and Dietetics. 2015;115(8):1323–1334. 33 Academy of Nutrition and Dietetics. Evidence Analysis Library. http://www.andeal.org/topic.cfm?menu=5284&cat=4085 Accessed June 20, 2015. 34 Boyce B. Emerging paradigms in dietetic practice and health care: Patient Centered Medical Homes and Accountable Care Organizations. Journal of the Academy of Nutrition and Dietetics. 2015;115(11):1765-1770.

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provider organizations to think creatively about the skill sets of providers such as RDNs and NDTRs 35, and to utilize them to the full extent of their training. Barriers to Nutrition Care and Access to RDN Services Changes in plan benefit design and coverage policies have lagged behind transformations in health care delivery. 36 Payers have the opportunity to revisit medical policies to ensure that they encourage access to cost-effective nutrition services as well as to work with purchasers to redesign benefits that are in alignment with population needs for both prevention and optimal management for chronic disease. Understanding plan benefits for MNT in the fee-for-service system is difficult and confusing for patients and for providers in the role of referring or coordinating care. Such confusion often results in the delay or absence of care, versus provision of care that could delay or prevent the onset of disease and/or limit disease progression. Centers for Medicare and Medicaid Services (CMS) conditions for coverage for MNT delivered by RDNs or qualified nutrition professionals are highlighted below. While some private insurance companies and some state Medicaid programs also cover MNT services, similar to the current Medicare program, this coverage is often limited in terms of the variety of conditions and diseases covered, the intensity of coverage, and the site of service provision. Furthermore, unlike the Medicare program, some payers may use physicians in addition to or instead of nutrition experts (RDNs) and/or create barriers to access through limited provider networks. The current Medicare program offers too little nutrition care, too late, and does not incentivize the use of other members of the health care team with specific expertise in areas such as nutrition counseling (i.e., RDNs). Under Section 2713 of the Affordable Care Act, health plans must include coverage for a range of US Preventive Services Task Force screening and counseling services 37 with Grade A or B recommendations, including diet counseling for cardiovascular disease prevention, obesity screening and counseling in adults and children, and as of October 2015, intensive behavioral counseling interventions to promote a healthful diet and physical activity in persons with abnormal glucose levels.38 Current payer and provider organization policies may not necessarily encourage utilization of the most cost-effective providers in the most cost-effective settings.

• Diagnosis o Medicare presently only covers outpatient medical nutrition therapy services provided by

RDNs for beneficiaries with diabetes, chronic renal insufficiency/non-end stage renal disease (non-dialysis) chronic kidney disease (CKD), or post kidney transplant 39

35 Nutrition Dietetic Technicians, Registered — NDTRs — are educated and trained at the technical level of nutrition and dietetics practice for the delivery of safe, culturally competent, quality food and nutrition services. They are nationally credentialed and are an integral part of health care and foodservice management teams. They work under the supervision of a registered dietitian nutritionist when in direct patient/client nutrition care; and they may work independently in providing general nutrition education to healthy populations. 36 Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. Washington (DC): National Academies Press (US); 2010. http://www.ncbi.nlm.nih.gov/books/NBK53906/ Accessed April 8, 2016. 37 http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/ Accessed February 4, 2016 38 http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/ Accessed February 4, 2016 39 Center 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 February 18, 2016.

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o Coverage does not include MNT for prediabetes o Benefits and coverage for MNT and nutrition counseling for diabetes and other conditions

are non-existent or vary significantly with both commercial plans and Medicaid • Site of service

o Provision of nutrition services in ambulatory care clinics and other outpatient office settings is generally covered for the diseases/conditions mentioned above

o Professional nutrition services delivered in acute care and most post-acute care settings are not reimbursed (exception: some limited reimbursement in home care)

o MNT can be administered to Medicare beneficiaries via telehealth, however there can be considerable limitations in originating sites and coverage for MNT delivered via telehealth among private payers and states

• Continuity of Care o The current Medicare benefit for MNT is as follows: 3 hours of face-to-face service for DM

and CKD in the first year that a patient presents for care; 2 hours annually in subsequent years

o Evidence-based practice guidelines have not been used to inform length of service o The process to obtain coverage for medically necessary services beyond these limits is

onerous and requires re-referral with changes in disease progression • Eligible Provider Status for MNT, IBT and Preventive Services Under the Affordable Care Act

o The Medicare Intensive Behavioral Therapy (IBT) for Obesity benefit must be billed by a primary care provider in a primary care office setting, despite the RDNs’ recognition as an eligible professional by CMS and as “the nutrition provider” in overweight and obesity management in the most recent joint treatment guidelines.40 RDNS are also recognized by the Institute of Medicine as the “single identifiable group of health-care professionals with standardized education, clinical training, continuing education and national credentialing requirements to be directly reimbursed as a provider of nutrition therapy as highly qualified providers in the treatment of obesity.”41 RDNs are not eligible billing providers for IBT for Obesity under Medicare.

o Under the Affordable Care Act, payers have the flexibility to determine eligible providers for the delivery and payment of Grade A and B preventive screening and counseling services. In many instances payers may not be recognizing and/or enabling the most cost-effective provider to deliver and be paid for nutrition-related preventive services mandated under the ACA, or other plan benefits for nutrition-related preventive services.

o Some state Medicaid programs do not recognize RDNs as eligible providers for billing purposes, thereby limiting consumers to the often less effective services provided by a physician, in a physician office, and at a higher cost.

40 Jensen, 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. 2014;129(suppl 2):S102-S138. 41 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.

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Alternative Payment Models, along with changes related to benefits, coverage and medical policies could collectively facilitate appropriate and timely care with more cost-effective providers and save stakeholders money. Population Management and Gaps in Cost Effective Nutritional Care An important paradigm shift in health care delivery has been articulated by both the private sector and federal government, stated in the goals of the Triple Aim 42 framework (improve population health, decrease per capita cost, improve the patient experience) from the Institute for Health Improvement in 2007, and CMS’s “Better Care, Smarter Spending, and Healthier People” announced by the Department of Health and Human Services in January of 2015. 43 The use of data for population identification and risk stratification is essential to understanding disease burden within populations, and for payers and provider organizations in developing interventions and leveraging the most cost-effective providers and services to improve the health of populations. Payers and provider organizations can tap into the unique education, training and competencies of RDNs at the organizational, network and practice levels, to develop and implement population based strategies around acute/chronic care, and in training licensed and non-licensed providers to deliver select services in a cost-effective way. The Appendix: Levels of Routine and Specialized Nutrition Services Provision within the DM Disease Continuum provides specific examples of the myriad of services provided by RDNs that payers and provider organizations could leverage at various levels of acuity in diabetes and other conditions, and throughout the lifespan. The following table provides a high level overview of services, current gaps in care, and possible payment model scenarios.

42 The Institute for Health Improvement. http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx Accessed Sept. 27, 2016. 43 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-2.html Accessed Sept. 27, 2016.

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Level 1: Primary Prevention/Low

Acuity)

Community Assessemnt & Program Development,

Screening;Education/Monitoring; Community Resources ; MNT-

prediabetes

Fee-for-Service; Fee-for-Service with Links to

Quality; Population-Based Payments

Lack CPT Code(s) for Nutrition Screening

Level 2: Secondary Prevention/Moderate

Acuity

Nutrition, Knowldege/Skills

Assessment; MNT, DSMTGoals Setting,

Intervention & Monitoring; Care Coordination Case

Management

Fee-for-Service with links to Quality; Episode or

Condition-Based Payment; Population-Based

Payments

Self Management Training (98960-62) Team Conference

(99441-43) Phone Codes (98966-69) Analysis Computer

Transitted Data (99091) inconsistently reimbursed; RDN

payment for interpretation/report of CGM (99251);MNT for prediabetes-

Metabolic Sx, home visits

Level 3: Tertiary Prevention (High

Acuity)

Nutrition Reassessment, Functional Status

Assessment; Goals Revision;Re-education;

Care Coordination; Case Management; Referral as

appropriate

Fee-for-Service &/or Episode- or Condition-

Based; Population-Based Payments

As above, transitions of care, home visits

inconsistently reimbursed

Level 4: Catastrophic Care

Adapt services to patient status/acuity level

Fee-for-Service with links to Quality; Episode- or

Condition-Based Payment; Population-Based

Payments

Reimbursement for RDN services across all acute and post acute settings

include Chronic Care (99487, 89) Transitional

Care (99495-96)

Primary prevention is controlling modifiable risk factors to avert the occurrence of disease; secondary prevention is the early detection of disease before it manifests clinical symptoms; and tertiary prevention is the control of existing diseases to prevent more serious complications Source: Yong PL, Saunders RS, Olsen LA, The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary, Institute of Medicine (US) Roundtable on Evidence-Based Medicine 2010 http://www.ncbi.nlm.nih.gov/books/NBK53914/ Accessed Sept. 27, 2016.

Level of Intervention Examples of Services Payment Models Coverage/Payment Gaps

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Nutrition therapy is an integral component of diabetes prevention, management, and self-management education, and the American Diabetes Association recommends that all individuals with diabetes should receive individualized MNT, preferably provided by an RDN. MNT goals are broader than weight loss goals in diabetes care, and nutrition therapy is essential throughout the disease process. The 2016 Standards of Medical Care in Diabetes include recommendations on “tailoring treatment to vulnerable populations with diabetes, including those with food insecurity, cognitive dysfunction, and /or mental illness and HIV,” and the importance of addressing differences and disparities. 44 The nutrition assessment process used by RDNs routinely considers patient psychosocial status, ethnicity, culture and religious preferences, literacy, numeracy and health literacy. 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. It generally encompasses all elements of the Academy of Nutrition and Dietetics Nutrition Care Process. 45 MNT may be defined broadly or more narrowly as the needs of the patient are identified during each stage of the disease continuum. Timely and appropriately intensive nutrition/lifestyle care should be provided for all people that have or are at risk for the development of DM. Nutrition services delivery is coordinated with a proactive medical team to ensure the provision of a patient-centered approach to care. Every effort is made to inform, engage, and involve patients and caregivers in the care process. Alternative Payment Models provide an opportunity for payers to design health care payments that incentivize the “right care” - not the most expensive care, encourage provider organizations to use cost-effective providers, such as RDNs, to deliver care and/or to provide other services (DSME, case management, and smoking cessation) at a lower cost than other providers. The following evidence-based assumptions are used in the models proposed to illustrate estimated costs and cost savings. Assumptions: Evidence-Based Nutrition Interventions Provided by RDNs in Diabetes Care Reduction in Avoidable Admissions and Physician Visits

• The Lewin Group documented a 9.5% reduction in hospital utilization in persons with diabetes mellitus.

• 23.5% reduction in physician visits when MNT was provided to persons with diabetes mellitus. • 8.6% reduction in hospital utilization was seen in persons with cardiovascular disease. Costs

associated with medication use decreased in both groups as well.46 • MNT was associated with a decrease in length of stay, fewer hospitalizations, and a $10,000

decrease in lower average monthly health care costs in a high risk population with chronic disease compared with controls. 47

44 American Diabetes Association standards of medical care in diabetes 2016. The Journal of Applied Clinical Research and Education, Diabetes Care. January 2016; 39 (supplement 1): 1-119. 45 Academy of Nutrition and Dietetics’ Definition of Terms list. https://www.eatrightpro.org/scope/. Accessed April 2, 2014. The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans. 46 Johnson R. The Lewin Group. What does it tell us, and why does it matter? J Am Diet Assoc. 1999; 99: 426-427. 47 Gurvey J. Examining health care costs among MANNA clients and a control group. Journal of Primary Care and Community Health. 2014; 4(4):311-317.

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Cost Effectiveness • Ten studies were reviewed to evaluate the cost effectiveness, cost benefit and economic savings of

outpatient MNT involving in-depth individualized nutrition assessment and a duration and frequency of care using the Nutrition Care Process to manage disease.

• Using a variety of cost- effectiveness analyses, several studies affirm that MNT resulted in improved clinical outcomes and reduced costs related to physician time, medication use and/or hospital admissions for people with obesity, diabetes and disorders of lipid metabolism, as well as other chronic diseases. 48

Return on Investment

• According to a 2013 Blue Cross Blue Shield study, “[health] plans that have added nutrition (RDN) services to their benefits packages (up to unlimited visits) report the additional cost has been 3 cents per member per month.” 49

• A 2001 study conducted at Massachusetts General Hospital demonstrated a savings of $4.28 for each dollar spent on MNT. 50

• Another study found that for every dollar invested in an RDN-led lifestyle modification program there was a return of $14.58.51

• The Department of Health and Human Services found that nutrition services for obesity alone reduce premiums by 0.05% to 0.1%. 52

Sustained Reductions in Hemoglobin A1c The provision of RDN services resulted in:

• 0.3% to 2.0% reduction in adults with type 2 diabetes in the first six months • 2% reduction in newly diagnosed type 2 diabetes when A1c is 9% 53 • 0.5% reduction in A1c in persons with type 2 diabetes living with diabetes for at least 9 years. The

0.5% reduction in A1c was more cost-effective than a third medication 54 • 1.0% to 1.9% reduction in adults with type 1 diabetes during the first six months • Improvements in A1c are achieved in three to six months, (3-11 encounters; 2-16 hours),

depending on the type and duration of diabetes. • Studies longer than six months report that continued MNT encounters resulted in maintenance and

continued reductions of A1c for up to two years in adults with type 2 diabetes, and for up to 6.5 years in adults with type 1 diabetes.

48 Academy of Nutrition and Dietetics. Evidence Analysis Library. http://www.andeal.org/topic.cfm?menu=5284&cat=4085 Published 2009. Accessed Sept. 13, 2016. 49 Bradley DW, Murphy G, Snetselaar LG, Myers EF, Qualls LG. The incremental value of medical nutrition therapy in weight management. Managed Care. 2013;22(1):40-45. 50 Delahanty LM, Sonnenberg LM, Hayden D, Nathan DM. Clinical and cost outcomes of medical nutrition therapy for hypercholesterolemia: A controlled trail. J Am Diet Assoc. 2001;101:1012-1016. 51 Wolf AM, Siadaty M, Yaeger B, et al. Effects of lifestyle intervention on health care costs: Improving Control with Activity and Nutrition (ICAN). J Am Diet Assoc. 2007; 107(8):1365-73. 52 Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act, 75 Fed. Reg. 41736 (July 19, 2010). 53 UK Prospective Diabetes Study (UKPDS) 7. Response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients. Metabolism. 1990; 39:905-912. 54 Coppell/LOADD study, cited by Franz M, Boucher J, Evert A. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014: 7; 65-72.

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• Studies that demonstrated reductions in A1c also demonstrated optimization of medication therapy and improved quality of life. 55

Decreased Use of Medication or Optimization of Medication Therapy 56

• MNT provided by RDNs resulted in decreases in doses or the number of glucose-lowering medications used in adults with type 2 diabetes in 12 study arms, from 11 studies. Interventions included 3 to 10 encounters with RDNs, totaling 2 to 6 hours.

• A1c improved in adults with type 1 diabetes when RDNs implemented carbohydrate counting for the adjustment of pre-meal insulin doses. Although the number of insulin injections increased, HbA1c improved without an increase in total insulin doses. Results were achieved with 4-6 encounters.

Improvement in Biochemical Results and Anthropometric Measurements • Strong evidence supports the effectiveness of nutrition interventions and counseling provided by a

nutrition professional (RDN) as part of the health care team. Improvements in the following have been demonstrated in a variety of conditions (overweight, eating disorders, diabetes, renal disease, amyotrophic lateral sclerosis (ALS), cardiovascular disease, and osteoporosis) in at least three dozen studies that included a nutrition professional as part of the multi-disciplinary team 57:

o Weight, BMI, waist circumference, hip circumference o Fasting blood glucose, HbA1c, fasting insulin homeostatic model assessment-estimated

insulin resistance o LDL-cholesterol, HDL-cholesterol

Blood Pressure Control

• Several studies reported decreases in systolic and diastolic blood pressure in adults with type 2 diabetes. 58

Positive Outcomes with RDN Case Management

• 12-month quality of life scores were significantly better for adults with type 2 diabetes receiving case management from RDNs than adults receiving usual care.

• Three studies reported significant improvements in quality of life (satisfaction with treatment and psychological wellbeing) despite increases in insulin injections or diet requirements. 59

55 Evidence Analysis Library Project 2015. www.andevidencelibrary.org/mnt 56 Academy of Nutrition and Dietetics. Evidence Analysis Library. www.andeal.org/dm Published 2015. Accessed Sept. 13, 2016. 57 Academy of Nutrition and Dietetics. Evidence Analysis Library. http://www.andeal.org/topic.cfm?menu=5284&cat=5233 Published 2015. Accessed Feb 4, 2016. 58 Academy of Nutrition and Dietetics. Evidence Analysis Library. www.andeal.org/dm Published 2015. Accessed Sept. 13, 2016. 59 Bastiaens H, Sunaert P, Wens J, Sabbe B, Jenkins L, Nobels F, Snauwaert B, Van Royen P. Supporting diabetes self-management in primary care: pilot-study of a group-based programme focusing on diet and exercise. Prim Care Diabetes. 2009; 3(2): 103-109.

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Framework for the Integration and Payment for Services Provided by RDNs in APMS Payers have an opportunity to engage provider organizations and network providers in the delivery of cost-effective nutrition care through the use of the various categories and subcategories of APMs established by the Health Care Payment Learning & Action Network and published in a white paper in January of 2016.60 The following examples illustrate how payers and provider organizations can allocate spending for nutrition care provided by RDNs to improve health outcomes and achieve a cost savings in different types of APM arrangements. Supplemental exercises to determine costs will sometimes be necessary to establish accurate financial benchmarks for the delivery of nutrition services, given the dearth of historical claims and encounter data.

Costs Attributed to Diabetes/case 61 CMS Fee Schedule 62 *Services provided by RDNs in diabetes may include, although not limited to the following: individual or group MNT, Intensive Lifestyle Interventions, Shared Medical Visits, Group Nutrition Visits, Diabetes Self-Management & Education, Diabetes Self-Management & Training, obesity management for the treatment of type 2 diabetes, case management, smoking cessation, Continuous Glucose Monitoring training delivered in the most cost-effective settings 60 Health Care Payment Learnin & Action Network. Alternative payment model framework final white paper. https://hcp-lan.org/groups/apm-fpt/apm-framework/. Published January 12, 2016. Accessed February 19, 2016 61 American Diabetes Association. The Cost of Diabetes. http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html?referrer=https://www.google.com/ Reviewed October 21, 2013. Updated June 22, 2015. Accessed February 26, 2016 62 https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=4&HT=2&CT=0&H1=97802&H2=97804&M=5 Accessed February 26, 2016.

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Category: Fee-For-Service with links to quality & value FFS Payments for High-Value Nutrition Services: There are several categories of alternative payment models, 63 yet payers are likely to benefit from expanding some fee-for-service payments for services already demonstrated to be cost-effective, and that are under-utilized in the current fee-for service model. Evidence provided in the assumptions section suggest that payers may be able to spend more on fee-for-service payments for MNT and still spend less on overall care, and potentially more so, when such payments are tied to quality. Fee-for-service payments enable RDNs to serve payer populations through inter-professional health care teams in fully integrated delivery models, as part of the greater medical neighborhood, and in experimental delivery and payment models.

Benefit design that includes MNT (CPT® codes 97802, 97803, and 97804) delivered by RDNs throughout the continuum of care may eliminate the need for higher-cost services. Payers should also consider recognizing RDNs as eligible rendering and billing providers for additional services that are within the scope of practice of the RDN, but where the RDN is currently not an eligible billing provider. Some examples of services (and corresponding CPT® codes) that could be delivered by an RDN at a lower cost include:

• Education and Training for Patient Self-Management 98960-62 • Telephonic Services Conferences 98966-69 • Medical Team Conferences 99366-99368 • Collection and Interpretation of Physiologic Data 99091 • Complex Chronic Care Management Services 99487, 99489 • Transitional Care Management Services 99495-96 • Chronic Care Management 99490 • Ambulatory Continuous Glucose Monitoring Interpretation and Report 95250-51 • DSME/T as independent provider G0108-09

In return, payers are encouraged to engage RDNs and consider them as “eligible providers” in quality and performance-based incentive programs where robust methodologies can be used to assign the RDN provider attribution, whether the RDN is working independently or as part of a team. Continuation of fee-for-service payments may help payers and provider networks ensure important patient access to specialized services provided by RDNs during transitions to other types of alternative payment models, or to pay for services that may fall outside the construct of other types of alternative payment models.

Payers can also encourage provider organizations receiving foundational payments to improve care delivery to use RDNs to improve health outcomes in specific populations, achieve performance benchmarks, perform other roles, and enable the practice to simultaneously develop and implement prevention strategies.

63 Health Care Payment Learning and Action Network. Alternative payment model framework final white paper. https://hcp-lan.org/groups/apm-fpt/apm-framework/ Published January 12, 2016. Accessed February 19, 2016

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Fee-For-Service with Links to Quality and Value Scenario #1: Pre-diabetes and prevention interventions Clinical trials provide evidence for the effectiveness of nutrition therapy in the prevention of diabetes. In individuals who have maintained lifestyle strategies for prevention of diabetes, the effectiveness of these strategies has been maintained for 10 years and longer when lifestyle interventions were delivered by RDNs.64 Of the 86 million individuals with prediabetes, 35% are at “high” or “very high” risk of developing diabetes. Without lifestyle changes to improve their health, 15% to 30% of people with pre-diabetes will develop type 2 diabetes within five years.65 These populations may require more specialized, directive and personalized care to prevent diagnoses than community-based prevention programs which utilize both licensed and non-licensed providers. The use of NDTRs, who work under the supervision of RDNs when engaged in direct patient/client nutrition care activities in any setting, could help ensure the delivery of high quality community-based prevention programs. NDTRs are also qualified to provide nutrition information and guidance related to population-based public health initiatives for healthy populations.66 The specialized training and competencies of the RDN and the use of NDTRs with a standardized, evidence-based educational background and competencies in nutrition will improve the quality of interventions and alleviate the burden on physicians to provide nutrition education to prevent or delay diabetes diagnoses. 67

Costs to delay or prevent diagnosis 68 in high risk for at least 1 year 69 Examples of services provided by RDNs in diabetes may include, although not limited to the following: individual or group MNT, Intensive Lifestyle Interventions, Shared Medical Visits, Group Nutrition Visits, Diabetes Self-Management & Education, Diabetes Self-Management & Training, obesity management for the treatment of type 2 diabetes, case management, smoking cessation, Continuous Glucose Monitoring training delivered in the most cost-effective settings

64 Matte M and Velonakis, E. Type 2 diabetes programs: how far are we? Journal of Diabetes & Metabolism 2014: 5:11. 65 http://www.cdc.gov/diabetes/basics/prediabetes.html. Accessed March 2016 66 Scope of Practice for the Dietetic Technician, Registered. J of Acad of Nutrition & Dietetics. 2013; Vol 113(6)(Suppl 2): S46-55 67 ibid 68 Li R,Zhang P, Barker L, Chowdhury F, and Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes Care. 2010; 33(8):1872-1894 69 https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=4&HT=2&CT=0&H1=97802&H2=97804&M=5

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Scenario #2 – Diabetes Populations with Comorbidities and Complications “Even in patients with a long duration of type 2 diabetes of approximately 9 years and diabetes that was not optimally controlled, implementation of nutrition therapy reduced A1c by 0.5%, which was significant and more cost-effective than adding a third medication.” 70

Costs: Coronary heart disease, congestive heart failure, hemiplegia, and amputation were each associated with 70% to 150% higher costs. Costs were approximately 300% higher for end-stage renal disease treated with dialysis and approximately 500% higher for end-stage renal disease with kidney transplantation.71 Examples of services provided by RDNs in diabetes may include, although not limited to the following: individual or group MNT, Intensive Lifestyle Interventions, Shared Medical Visits, Group Nutrition Visits, Diabetes Self-Management & Education, Diabetes Self-Management & Training, obesity management for the treatment of type 2 diabetes, case management, smoking cessation, Continuous Glucose Monitoring training delivered in the most cost-effective settings

70 Coppell/LOADD study, cited by Franz M, Boucher J, Evert A. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2014: 7; 65-72 71 Rui Li PhD, et al. Medical costs associated with type 2 diabetes complications and comorbidities. Am J Manag Care. 2013; 19(5):421–430

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APM Category: Bundled and Episode-Based Payments The use of bundled and episode-based payments to facilitate the delivery of care from multiple providers over a defined period of time or course of treatment, with payments based on cost performance against a financial benchmark, is growing. Payers and provider organizations have an opportunity to better meet cost targets, improve outcomes, achieve performance and quality benchmarks, and ultimately reduce the total cost of care by factoring the cost of MNT and other services provided by RDNs when setting cost targets. Episodes and corresponding payments that enable flexibility for RDNs to provide care across settings, including hospital, ambulatory, skilled nursing facility, rehabilitation, and home will facilitate the delivery of personalized care likely to increase patient engagement and health outcomes while reducing the cost of care for the episode. RDNs may be able to facilitate transitions of care or coordinate care at a lower cost than many other providers. In addition to the review of historical claims and encounter data to establish cost targets for episodes and bundles, stakeholders can consider additional sources of information including standards of practice, clinical guidelines and experimental models to better understand the most cost-effective care. Claims data is likely to be insufficient given gaps in coverage and payment, which are important factors in the underutilization of cost-effective services provided by RDNs in the fee-for-service model. Factoring the cost of specialized nutrition care into episode or condition-based payments for chronic kidney disease, gestational diabetes, bariatric surgery, medical weight management services, congestive heart failure, specific comorbidities, and other conditions (e.g., cancer) may make sense for all stakeholders.

CMS Fee Schedule for Medical Nutrition Therapy CPT Codes 97802, 97803, and 97804 72

72 https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=4&HT=2&CT=0&H1=97802&H2=97804&M=5 Accessed Sept. 27, 2016.

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Category: Population-Based Payments 73 Condition-Specific Population-based Payments and Comprehensive Population-based Payments are ways for payers and provider organizations to encourage and enable inter-professional teams to effectively manage the longitudinal care of specific populations with diabetes in a cost-effective way. Population-based payments ideally incentivize provider teams to deliver health care services and engage patients in strategies that will improve health outcomes over the long term, rather than to provide services that yield the greatest revenue in the short term. Payers and provider organizations will benefit from factoring in the cost of delivering evidence-based nutrition care into population-based payments, as these services have been demonstrated to be cost-effective. To do so, stakeholders may wish to consider additional sources of information including standards of practice, clinical guidelines, and experimental models to better understand the most cost-effective care. Claims data is likely to be insufficient given gaps in coverage and payment, which are important factors in the underutilization of cost-effective services provided by RDNs in the fee-for-service model. Individualized MNT for diabetes, Diabetes Self-Management and Education, specialized diabetes care, and tailored treatments to vulnerable populations provided by RDNs have demonstrated improvement in health outcomes and the RDN has been identified as an important component of the inter-professional team in diabetes care. Additionally, payers and health care teams can leverage the competencies of RDNs in shared medical appointments and group visits, care coordination, case management, and specific transitions of care, or to manage quality improvement or reporting activities. When delivered by an RDN, these services may be delivered at a lower cost than when delivered by many other providers. Payers, provider organizations, and interdisciplinary teams are encouraged to engage RDNs as accountable providers in quality and performance in population-based payments. Payers and provider organizations are likely to benefit from factoring the cost of evidence-based nutrition care into partial or full comprehensive-based payments.

73 Health Care Payment Learning & Action Network. Alternative payment model framework final white paper. https://hcp-lan.org/groups/apm-fpt/apm-framework/. Published January 12, 2016. Accessed February 19, 2016.

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Summary Documentation of the efficacy of evidence-based nutrition interventions provided by RDNs and the scenarios contained in this document offer examples of the myriad of ways in which RDN services can be readily incorporated into evolving delivery and payment models.

• Physicians, often hesitant to refer patients for needed but non-covered services, would have the opportunity to ensure timely and appropriate nutrition care for their patients via the use of a health care team that contains an RDN or through alternative payment streams that would make such care available and affordable.

• Health systems, ACOs, PCMHs have an opportunity to construct and to demand payment for health care teams that consistently provide high quality nutrition services and that include RDNs as essential members.

• Payers have a unique opportunity to revisit medical policies to ensure that they promote and support access to cost-effective MNT services, as well as to work with purchasers to redesign benefits that are in alignment with population needs for both prevention and optimal management of diet-related chronic disease.

Short and long-term health and economic benefits can be derived by the routine, timely delivery of nutrition services to prevent and/or to ameliorate the chronic diet-related diseases and other diseases/conditions where the presence and/or development of poor nutritional status results in negative health outcomes, increased, unnecessary health care utilization and increased costs.

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Additional References

1. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June;27(3):759-769.

2. Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook.[PDF - 10.62 MB]http://www.cdc.gov/Other/disclaimer.html AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality; 2014. Accessed June 20, 2015.

3. Health Affairs. 2009;28(5):w822-31. http://content.healthaffairs.org/content/28/5/w822.full.html. Accessed Mar 20, 2016.

4. Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. Washington (DC): National Academies Press (US); 2010.

5. Miller HD. Network for Regional Healthcare Improvement. Payment Reform Series No.3. The Building Blocks of Successful Payment Reform: Designing Payment Systems that Support Higher-Value Health Care. Center for Healthcare Quality and Payment Reform and Robert Wood Johnson Foundation. April 2015

6. Writing Group of the Nutrition Care Process/Standardized Language Committee. Nutrition Care Process and Model Part 1: The 2008 Update. J Am Diet Assoc. 2008. 108(7):1113-1117.

7. Writing Group of the Nutrition Care Process/Standardized Language Committee. Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process. J Am Diet Assoc. 2008. 108(8):1285-1293.

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

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Level of Care/Payment Options Goal of Care Care Plan Suggestions

Gaps in Care Associated with Delivery & Payment FFS Model

Level 1: Primary Prevention (Low Acuity)

• Fee-for-service Single/group - limited service(s) provision, e.g., screening

• Episode of care, e.g., education and/or training using a defined curriculum/number of classes

• Condition-based payment, e.g., self-limiting condition(s) such as pregnancy

• Population-based payment for prevention

Prevent disease onset

Children: Screening using established protocols for those at increased risk (overweight);

• Begin at age >10 years or onset of puberty; frequency: every 3 years

• Monitor for warning signs Individuals with cystic fibrosis;

• Nutrition assessment, carbohydrate intake aligned with prandial insulin therapy if instituted

Education and monitoring regarding: • healthy diet • adequate physical activity • prevention of smoking/illicit

substances use/abuse Link(s) to community resources/special services as needed Adults: Screening at 3-year intervals using established protocols for those at increased risk.

• Family history of diabetes • Begin at age 45 years for

overweight/obese • Treatment guidelines for

overweight/obesity

Although ICD-10 codes exist to document the need for Diabetes & Nutrition Screening (Z13.1, Z13.2, Z13.21), there are no CPT codes that document provision of this service. CPT codes for Education and Training for Patient Self-Management (98960-62) are available but are inconsistently recognized and/or reimbursed by CMS and other payers.

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

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• Frequency: if prediabetes screen annually; otherwise at 3-year intervals

• Monitor for warning signs Education and monitoring regarding

• healthy diet • adequate physical activity • smoking cessation • moderate alcohol

consumption • avoidance illicit substances

use/abuse Links to community resources/special services as needed Gestational DM:

• Assessment using approved testing protocol

• If diagnosed: - Nutrition status/physical activity/psychosocial assessment - Diet and exercise education (nutrition intervention services as described above with particular attention to type and distribution of carbohydrate intake) - Education regarding medications use as indicated - Lifelong monitoring (every 3 years)

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

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- Implementation of lifestyle interventions + metformin to prevent/treat post-partum development of DM

DM in Pregnancy; Type 1 or 2:

• Preconception counseling emphasizing importance of diet, activity and medications used to obtain/maintain strict glycemic control prior to conception and during pregnancy to reduce risk of congenital anomalies

• Avoid potentially teratogenic medications if not using reliable contraception in women of childbearing age

• Nutrition intervention as described below once pregnancy occurs

Level 2: Secondary Prevention (Moderate acuity)

• Episode of Care • Disease/Condition-based

payment - Single/multiple

providers - Warrantied

Treat a disease/ condition, delay progression, avoid serious complications/ comorbidities

Children and Adults: As above, plus: Pre-Diabetes, New Onset Types 1 & 2:

• Age/age at onset • Nutrition and physical activity

assessment • Nutrition-focused physical

exam • Behavioral/psychosocial

assessment • Nutrition diagnosis(s)

CPT codes for Education and Training for Patient Self-Management (98960-62) are available but are inconsistently recognized and/or reimbursed by CMS and other payers.

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

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• Discuss/establish blood glucose goals using (as appropriate to age/disease status) - diet control - oral medications - insulin basal + bolus dose

• RDN-provided/supervised coaching – Intensive lifestyle modification, individual or group or MNT, to accommodate home, school, work, sports environments

• RDN-provided diet, behavior and physical activity modification to delay/prevent hypo/hyperglycemia; onset of comorbidities

• Food selection/ shopping assistance, cooking tips, recipe modification/development, seasoning alternatives, etc., per patient preference and health status.

• Food, activity, medications records review; plan modification as indicated by self-monitoring data

• Identification of/nutrition interventions to address insulin resistance (diseases/conditions that

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

29

precede DM manifestation: hypertension, dyslipidemia, associated comorbidities)

• Smoking, beverage alcohol use assessment/cessation counseling if applicable

• RDN-provided/supervised structured follow-up/revision of plan as needed to accommodate changes in lifestyle/ nutrition status/disease risk

• Assess blood glucose logs, continuous glucose monitoring and/or insulin pump data for problem solving recurrent problems such as hyper-/hypo-glycemia; teaching new material/concepts

• Subsequent modification of dietary carbohydrate/nutrient content, texture, food selection/preparation methods per patient preference as health and nutrition status indicate

• Education regarding oral/injected medications use, insulin administration/pump (if indicated), continuous

CPT codes used to indicate provider review, assessment, interpretation of data are available but inconsistently recognized and/or reimbursed by payers: Analysis of Computer Transmitted Data (99091) for example blood sugar, Continuous Glucose Monitoring intervention and report (99250-99251); as well as others for blood pressure, INR values, etc.

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

30

glucose monitoring (if indicated)

• Education/ monitoring to recognize /prevent hyper-/hypoglycemia

• Assess understanding/ ability/level of agreement to self-manage DM

Team-Based Care – Types 1, 2 & GDM

• Nutrition/lifestyle coaching • Group visits • Home visits • RDN-supervised peer support • Care coordination – home,

school, work, sports, etc. • Case management • Home self-monitoring • Self-management education • Use of relevant medical team

members to provide: health coaching, pre-surgical assessment (e.g., bariatric surgery), case management, coordination of care, communication and exchange of information with other providers/health care settings

• Referrals, as appropriate

CPT Medical team conference codes (99366-68); telephone services codes (99441-43 and 98966-69) are available for use but are inconsistently recognized/reimbursed by CMS and other payers.

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

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Level 3: Tertiary Prevention (High acuity)

• Episode of care/Condition-based Payment

• Comprehensive Care/Population-based payment - Single /multiple

provides(s) - Warrantied

Treat later stages of disease, condition/ multiple comorbidities; minimize disability

Children and Adults Type 1 &2: Additional nutrition assessment/reassessment, diagnosis, intervention and monitoring as needed to manage any diet-related disease(s)/additional loss of function that develops:

• Heart disease: hypertension, dyslipidemia(s), CHF, MI, CVA, etc.

• Renal insufficiency/failure • Neuropathy • Skin/foot complications • Eye complications • Gastroparesis • DKA/ketoacidosis • Hypoglycemia

Team -based Care :

• Nutrition/lifestyle coaching • Group visits • Home visits • RDN-supervised peer support • Home self-monitoring • Self-management education • Use of relevant medical team

members to provide: case management, pre-surgical assessment (nutrition status/routes of

CPT Medical team conference codes (99366-68); telephone services codes (99441-43 and 98966-69) are available for use but are inconsistently recognized and/or reimbursed by CMS and other payers.

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

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food/nutrient administration), Anti-coagulation management (i.e., medication, food/supplements interaction, dose adjustment(s) per protocol), coordination of care, communication and exchange of information with other providers/health care settings

• Referrals, as appropriate

CPT codes for anticoagulation management (99363-64) are available for use but are inconsistently recognized/reimbursed by CMS and other payers.

Level 4: Catastrophic Care (Very high acuity)

• Episode of Care + Comprehensive Care Combination Payment Model - Single/multiple

provider(s) - Warrantied

Restorative care when possible; otherwise provide comfort care alternatives

Children and Adults, Type 1 &2: Nutrition services delivery as described above in the context of the following settings:

• Hospitalization • Rehabilitation • Long-term care • Hospice/palliative care

Team-based Care:

• Support groups • Nutrition/lifestyle coaching • Intensive nutrition care plan

management/personalization; assess adequacy of additional resources needed (food/nutrition, economic, caregiver, etc.) to address patient’s current status

• Group visits

The provision of the services of nutrition professionals, e.g., nutrition screening, nutrition assessment, enteral/parenteral nutrition prescription and management, nutrition education and training, anticoagulation management (per protocol) should be recognized and in acute care settings reimbursed separately from “room and board” under which these services are currently categorized.

Appendix: Levels of Routine and Specialized Nutrition Services Provision within the Diabetes Mellitus Disease Continuum

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• Home visits • RDN-supervised peer support • Home self-monitoring • Self-management

education/monitoring • Use of relevant medical team

members to provide: health coaching case management, coordination of care, communication and exchange of information with other providers/health care settings

• Referrals, as appropriate

CPT codes for the following services are available yet inconsistently recognized and/or reimbursed by payers, including CMS: complex chronic care management (99487 and 89); transitional care management (99495-96); Medical team conference codes (99366-68); telephone services codes (99441-43 and 98966-69)