The Right Care at the Right Time: Integrating Nutrition Care for Diabetes into Primary Care Academy of Nutrition and Dietetics September 6th 2017 This presentation is provided free-of-charge and is supported by Grant Number 1L1CMS-331480-01-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.

Amy Allen serves as a Member of the Nutrition Services Payment Committee for The Academy of Nutrition and Dietetics. She received her bachelors of Art from Kalamazoo College in Kalamazoo, MI, and completed her Registered Dietitian Internship and earned a Master’s degree of Public Health, Human Nutrition & Dietetics in Environmental Health Sciences from the University of Michigan. She has worked in this field for seven years. Amy Allen, MPH RDN

Nothing to disclose Disclosure Speaker Notes: For today’s meeting: We will go over the MACRA legislation and the two pathways within the MACRA Quality Payment Programs. How you as a provider can prepare for these alternative payment programs under MACRA with TCPI, or The Transforming Clinical Practice Initiative. We will provide an overview of the Transforming Clinical Practice Initiative and discuss the two key components to TCPI – Support and Alignment Networks (SAN) and the Practice Transforming Networks. The TCPI is critical as it ushers in a new era of practice that shifts its focus from “volume” to “value” and what does this new payment system mean. We will discuss the criteria for TCPI participation and the benefits to doing so. If time allows, we will take the opportunity to address your questions.

Objectives Describe how Medical Nutrition Therapy (MNT) improves outcomes in populations with diabetes Integrate nutrition care for diabetes and related chronic conditions into various primary care models Estimate the potential revenue streams for nutrition services provided by RDNs in primary care

National Diabetes Statistics Report, 2017 30.3 million people have diabetes 23.1 million diagnosed 7.2 million undiagnosed 12 million among those aged 65 years or older 132,000 children & adolescents < 18 years of age Centers for Disease Control

What is Medical Nutrition Therapy (MNT)? An evidence-based nutrition service provided by RDNs to prevent, delay or manage diseases and conditions A personalized, in-depth assessment, nutrition diagnosis and intervention treatment plan Provided over multiple visits to positively impact nutrition behaviors and allow for continued personalized monitoring of the patient/client

The Nutrition Care Process Includes Nutrition Screen/Referral Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation Nutrition Documentation Outcomes Management

Alignment with National Practice Guidelines Standards of Medical Care in Diabetes

MNT Improves A1c & Reduces Cost 0.3-2.0% reduction in A1C 1st 6 months (UKPDS) 2% reduction in newly diagnosed when the A1C > 9% (LOADD study) 0.5% reduction in A1C in persons with Type 2 DM for ≥ 9 years with sub-optimal control More cost-effective than adding a third medication (LOADD study) 9.5% reduction in hospital utilization (Lewin Group)

Impact of Reduced Glycemia Lower A1C levels are associated with reduced onset or progression of microvascular complications.” 1% ↓ mean A1C levels associated with risk reductions: 21% for death related to diabetes 14% for myocardial infarction 37% for microvascular complications = ↓ avoidable spending (saves $)

Risk Factors for Complications of Diabetes Smoking Overweight and Obesity Physical Inactivity High Blood Pressure High Cholesterol (Hyperlipidemia) High Blood Glucose (Hyperglycemia) National Diabetes Statistics Report, 2017

Revenue from Services Provided by RDNs?

Codes for Medical Nutrition Therapy (MNT) CPT® codes Description Key Information 97802 Initial assessment and intervention Individual face-to-face and via telehealth Time-based code (15 minutes/unit) 97803 Reassessment and intervention individual face-to-face, and via telehealth (15 minute/unit) 97804 MNT delivered in a group setting 2 or more individuals (30 minutes/unit)

When Patients Need More Care: MNT beyond the standard benefit (3 hours/2 hours) Required: 2nd referral from treating physician Criteria: medical necessity G0270 15 minutes Reassessment and subsequent intervention(s) following 2nd referral in same year individual, face-to-face  G0271 30 Same as above, but for groups of 2 or more individuals

Minimum Revenue Per Patient Standard Medicare benefit for MNT 2017 CMS fee schedule national rate/unit: 3 hours of individual MNT (1st year): 97802 x 4 units @ $29.89 = $119.56 97803 x 8 units @ $25.93 = $207.44 = $327.00 2 hours of individual (subsequent years) 97803 x 8 units @ 25.93 = $207.44 $534.44 per client for 1st two years

Improve Access to MNT via Telehealth

Related Services to Improve Care & Outcomes RDN Can Provide “Incident to” services: Intensive Behavioral Therapy (IBT) for Obesity Chronic Care Management Services Annual Wellness Visit (AWV) USPSTF Preventive Screening & Counseling

Integrating Nutrition- Getting Started

Business Relationship Employ an RDN (PT or FT) Independent Contractor Consultant Referrals to RDNs Private practice RDN or within IPA, medical group or system

Operationalizing Nutrition Care Population Management Services Practice Resources Delivery Measure outcomes/effectiveness

Set the Stage for Success Share confidence in the process, person and experience Explain what patient might expect Warm hand-offs Referral to an RDN to help patients live well with diabetes “Team sport” culture

Implementation Do Study Act Plan

Stories from the Field RDNs in Medical Homes Medication adjustment per protocol Manage registries Monitor labs Clinical quality targets Self-management Food insecurity pilot New service delivery methods

www.eatright.org/find-an-expert

Sources 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 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 American Diabetes Association Standards of Medical Care in Diabetes 2017 Stratton, I et al., Association of glycaemia with macrovascular and microvascular complications of Type2 diabetes (UKPDS 35): prospective observational study, 321 The British Medical Journal. 2000;Aug 405, 409 Sheils J, Rubin R, Stapelton D. The Estimated Costs and Savings of Medical Nutrition Therapy: The Medicare Population. J Acad Nutrition and Dietetics. 1999; 99(4): 428-435.

Q & A

Business Case For Nutrition Care-Academy of Nutrition and Dietetics Resource http://www.tcpisan.org/wp-content/uploads/2017/09/Patient-Centered-Nutrition-Services-Payment-Model_-FINAL-9-29-16.pdf Organizational contact for this resource is the Nutrition Services Coverage Team at the Academy of Nutrition and Dietetics : reimburse@eatright.org or 800-877-1600.

Thank you! Amy Allen, MPH, RD Allena@careoregon.org Member, Nutrition Services Payment Committee Academy of Nutrition and Dietetics