In a major victory for people with disorders caused or greatly impacted by their diet, new Medicare rules will allow coverage of nutrition counseling. The Medical Nutrition Therapy Act was signed into law in December 2000, and will take effect in January 2002.
According to the American Dietetic Association, passage of the bill reflects the growing understanding that nutrition plays a key role in the treatment of certain disorders. Although many conditions are affected by diet, the law will allow people with diabetes and kidney disease to work with registered dietitians to manage their disease upon referral from a physician. Currently, Medicare pays for doctor-ordered nutrition support when a patient is acutely ill and requires intravenous nutrition therapy. However, there has been no coverage for education or counseling for normal eating practices.
Lawmakers voted to delay launching the program until 2002 to give the U.S. Health Care Financing Administration time to work out such details as how many nutrition counseling sessions would be covered, how to structure reimbursement rates and which professionals would qualify to provide the therapy. HCFA administers the federal Medicare program.
"Congress wanted to give HCFA time to implement the benefit," says Jane V. White, president of the American Dietetic Association. "Medicare has never covered nutrition services before. And nutrition is not just treatment. You are getting into something that is a preventive service as well. This is a bit of a new realm for Medicare."
The Studies
The ADA, whose members are most likely to offer MNT, worked for almost 10 years to convince lawmakers that government dollars would be well spent on nutrition therapy. One study, published in the January 1999 Journal of the American Society of Nephrology, found that kidney dialysis (which costs Medicare almost $10 billion a year) can be delayed up to a year for patients who follow a low-protein diet. Another study on people with high cholesterol found that nutrition counseling helped 34 out of 67 Medicare patients avoid taking medications to lower cholesterol -- resulting in an annual savings of more than $60,000. The study was published in the October 1998 issue of the Journal of the American Dietetic Association.
The MNT bill received support when the Institute of Medicine, a highly respected advisory board to the federal government, released a report in 1999 saying that nutrition therapy will "improve the quality of care and is likely to be a valuable and efficient use of Medicare resources." The report noted that nutrition therapy is different than simple advice and counseling because therapy entails the possibility of altering the course of disease or reducing symptoms.
"It actually reduces health-care costs by giving people prevention measures," says Gail Frank, a professor of nutrition at California State University, Long Beach. "This is a monumental leap to say we can improve the well-being of a person with a chronic condition and reduce [death rates]."
Other studies, including a comprehensive analysis in November 1998, provided by a private research firm, the Lewin Group, for the Department of Defense, have shown that people who receive detailed nutrition counseling require fewer hospitalizations and medications and have fewer complications related to their disease.
Nutrition therapy offered by registered dietitians makes a difference, according to an October 1998 study published in the American Journal of Clinical Nutrition, because many doctors received little nutrition education in medical school and are often unprepared to offer patients detailed guidance on how to alter their diets to improve their health.
What Patients Will Receive
The new regulations will allow for a thorough look at how nutrition affects a particular individual, experts note. For example, Medicare will pay a dietitian to conduct a review of the patient?s diet history and for blood tests and other measures that determine nutritional status. After this initial assessment, the health professional will be able to recommend various nutritional treatments ranging from simple diet modification and counseling to specialized therapies, such as nutrition delivered by tube or via intravenous infusion.
In the first case, for example, a dietitian might meet regularly with a patient with diabetes to help the individual reduce protein intake, adjust calorie intake and monitor blood glucose levels.
In the second instance, dietitians can set up nutritional therapy via tubes or infusion for people with chronic obstructive pulmonary disease, cerebral palsy, cystic fibrosis, severe burns or other serious disorders. The nutritionist can help the patient progress to eating normal foods.
Although the federal government has yet to specify how many nutrition visits will be covered under the benefit, most experts believe it will be substantially more than a single session or two.
"It?s not going to be a one-time hit," Frank says. "Dietitians will be able to do an assessment, find out what the patient is eating and then really do therapy. We will have the opportunity over time -- six months to a year -- to treat."
Delay of the highly anticipated program, however, may pose a problem to some people who will qualify for Medical Nutrition Therapy but may not want to wait until January 2002 for counseling. According to White, individuals can take steps now to improve their diets by obtaining a copy of the U.S. Department of Agriculture?s Food Guide Pyramid (http://www.nal.usda.gov:8001/py/pmap.htm) and learning how to follow it.
"The food pyramid is a wonderful place to start," she says. "Another thing people can do is eat more vegetables. Walking two or three miles a day in 30 minutes is another good practice. Also, watch how much salt you eat and be moderate with alcohol intake."
Once the MNT benefit goes into effect, a dietitian can build on those healthy practices by helping individuals with advice that is tailored to them, such as how to shop for food and meal planning.
The ADA says it has already begun to work for expanded coverage under the law for people with heart disease, cancer, osteoporosis, AIDS and other conditions. An expansion of the Medical Nutrition Therapy act may be possible as lawmakers debate how to deal with the costs of Medicare prescription drug coverage.
"We know that MNT is effective for patients with heart disease, stroke, high cholesterol and other life-threatening conditions," says White. "We will continue our advocacy work in these areas in the hope that MNT may be offered under Medicare for these diseases as well."
