What Went Right? the Story of US Medicare Medical Nutrition Therapy

Elia M, Bistrian B (eds): The Economic, Medical/Scientiﬁ c and Regulatory Aspects of Clinical Nutrition Practice: What Impacts What? Nestlé Nutr Inst Workshop Ser Clin Perform Program, vol. 12, pp 137–158, Nestec Ltd., Vevey/S. Karger AG, Basel, © 2009. What Went Right? The Story of US Medicare Medical Nutrition Therapy Stephanie Patrick American Dietetic Association, Washington, DC, USA Abstract When President Lyndon Johnson signed the Medicare and Medicaid bill into law in 1965, it ended the 46-year campaign to enact a healthcare program for senior citizens and started what is now a 42-year effort by the American Dietetic Association (ADA) and its members to expand its coverage to ‘nutrition services’ for all appropriate diseases, disorders and conditions. In December 2000, Congress passed a Medicare Part B Medical Nutrition Therapy (MNT) provision, limited to patients with diabetes and/or renal disease, effective January 2002. In December 2003, the Medicare Modernization Act expanded access to MNT benefit and ADA continues to focus on the role of the registered dietician in MNT. Successful expansion of MNT benefits will require that ADA continues to demonstrate the cost-effectiveness and efficacy of nutrition counseling, as performed by the registered dietitian. Copyright © 2009 Nestec Ltd., Vevey/S. Karger AG, Basel The New York Times Business Section of March 11, 2007 included an article, ‘Knowledge is power only if you know how to use it’. Denise Caruso, executive director of the Hybrid Vigor Institute, wrote: ‘If we can land a man on the moon, why can’t we …?’ This ‘familiar, fill-in-your-pet-peeve lament about the state of the world since Neil Armstrong’s historic giant leap in 1969’ is a ‘question that continues to engage innovators and scholars’, she said. This document draws significantly from Medical Nutrition Therapy: The Core of ADA’s Advocacy Efforts (Part 1), published in the Journal of the American Medical Association, May 2005. The author thanks her colleagues and co-authors Ron Smith, Mary Hager and Pam Michael, professional staff of the American Dietetic Association, for their expert contributions. 137 Patrick For the purposes of this conference, let us begin by asking: If we can land a man on the moon, why can’t people receive life-saving medical nutrition therapy (MNT), as well as basic nutrition care, provided by the best trained professionals to provide such services? In her article, Caruso answered the question by separating ‘knowhow’ from ‘knowledge’. ‘Knowhow’, she said, ‘puts knowledge to work in the real world’. My presentation examines knowhow and knowledge, the concept of good for- tune, as well as extraordinary stamina. All are necessary to advance ideas in our complex world – and they are especially important when decisions are left to politicians. This document also examines the background rationale behind the American Dietetic Association’s (ADA’s) efforts in support of MNT, both as part of Medicare Part B and, more generally, as part of various national health insurance proposals. Integral to any discussion of MNT coverage history and ADA’s advocacy effort is acknowledging the larger issue and context of this effort: the US government’s struggle to pass a comprehensive national health insurance program (a part of which resulted in Medicare’s passage). When President Lyndon Johnson signed the Medicare and Medicaid bill into law, it ended the 46-year campaign to enact a healthcare program for senior citizens and started what is now a 42-year effort by ADA and its members to expand its coverage to ‘nutrition services’ for all appropriate diseases, disorders and conditions. After Medicare was enacted, ADA immediately recognized that not having nutrition and diet therapy services covered was a setback to the profession. As early as 1966 – one year after the enactment of the Medicare bill – the ADA House of Delegates voted to take the necessary action to include nutrition and diet therapy services in all medical care legislation. Although ADA lobbied for inclusion of nutrition services in various national health insurance plans during the 1970s–1990s, no bills were enacted. In support of those efforts, work continued in many venues. It was not until 1999 that major breakthroughs occurred. One of the prerequisites to getting Medicare coverage was the development of specific nutrition service codes, or current procedural terminology (CPT) codes, which set up the structure to distinguish MNT from other services in medical billing systems. Another important factor was the findings by the preeminent National Academies of Science Institute of Medicine that MNT was effective, and that registered dietitians (RDs) are uniquely qualified in providing MNT. Internally at ADA, other steps were occurring. Within months of these events, ADA adopted a new strategic plan defining the association’s mission as ‘leading the future of dietetics’, with a vision that ADA members would be the preferred providers of food and nutrition services. ADA became one of the first health professional associations to embrace evidence-based practice and outcomes analysis. 138 What Went Right? The Story of US Medicare Medical Nutrition Therapy In December 2000, Congress finally passed a Medicare Part B MNT provision as part of the Benefits Improvement and Protection Act, P.L. 106–554. The important features contained in the new MNT benefit are the following: • The benefit was limited to patients with only diabetes and/or renal disease • The decision to cover only diabetes and kidney diseases was based on cost projections by the Congressional Budget Office • The benefit was contingent on referral from a physician, with only an RD or licensed nutrition professional approved as providers • The Centers for Medicare and Medicaid Services (CMS) were directed to report to Congress on its recommendations on future expansion of the MNT benefit • The reimbursement rate was set at less than 80% of the actual charge for the services or 85% of the amount determined under the physician fee schedule for the same services if such services had been furnished by a physician • The benefit would become effective January 1, 2002 Other studies and events have incrementally advanced MNT in the United States. In March 2003, Medicare sent Congress recommendations on how to expand the MNT benefit. The key findings of that report were that dietary modification using MNT for patients with hyperlipidemia and hypertension also benefited patients, and MNT can help cancer patients eat and keep down foods as they endure chemotherapy. The Medicare Modernization Act, which Congress passed in December 2003, expanded access to the MNT benefit. There is an MNT component to the ‘Welcome to Medicare Physical’ benefit that went into effect in January 2005, and there is another stipulation that MNT be a part of Medicare’s disease management initiatives. Medicare Advantage, a managed care program, requires that participating private insurance companies include MNT for diabetes and renal diseases. Outside Medicare, Congress in 2006 made MNT a core medical service under the Ryan White CARE Act, our national program that provides assistance to persons with HIV/AIDS. Private insurers tend to follow Medicare, so diabetes and kidney disease MNT coverage are common, and some private insurers have provided finite coverage for weight management and other conditions. ADA continues to work for expanded Medicare MNT coverage so that any disease, disorder, or condition in which MNT is cost-effective will be offered. In 2007, we are particularly focused on diabetes screening and risk factors gaining coverage in Medicare and Medicaid, the health insurance program that covers a portion of the nation’s poor. In moving ahead, ADA is continuously asked if we can demonstrate the cost-effectiveness of MNT. The second question we face is: ‘What unique benefits are acquired from the services of a RD that are not available from other nutrition or healthcare professionals?’ 139 Patrick Both questions underscore the need to shift from traditional practice to evidence-based practice. Without adopting evidence-based practice, the dietetics profession will be unable to distinguish itself as the best provider of MNT, and RDs will not be able to successfully compete in a new healthcare environment where proven efficiency, cost-effectiveness, and sharing outcomes will be essential. The ADA’s official position is that ‘MNT not only improves the quality of life, but it reduces healthcare costs and hospital admissions for seniors with a number of serious conditions’. For that position to be viable, the profession must be able to justify the following three assertions: • RDs perform MNT better than anyone else • MNT improves the quality of life • MNT is cost-effective These assertions can only be defensible when dietetics professionals adopt evidence-based practice and document their competencies through positive outcomes, patient and provider satisfaction, and cost-effectiveness. This implies that the dietetics profession will undergo a paradigm shift in the per- formance of services. Medicare MNT providers must understand this shift and begin using the Nutrition Care Model and Process, which provides a frame- work for describing the specific components involved in providing MNT, such as nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluations. Medicare MNT providers must use evidence- based protocols or guides for practice to illustrate that the MNT offered by RDs has a positive medical impact on patients and a positive impact on healthcare budgets. Successful expansion of MNT benefits will require ADA not only to illustrate the cost-effectiveness and efficacy of nutrition counseling, but also to prove that such counseling performed by an RD is measurably different than counseling provided by other nutrition professionals. At that point, we may finally get past this long phase of working primarily with politicians. A Long Road and Many Steps The ADA established a government relations program in the 1960s.

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