CMS’ Decision to Cover Intensive Behavioral Counseling for Obesity for Eligible Medicare Beneficiaries
It is not secret that we have an epidemic of obesity in America among adults and children alike. Nor is it surprising to know that we have a huge problem with an increasing incidence of diabetes and cardiovascular disease, both due to their relationship to diet and weight. It is with great disappointment that Registered Dietitians are not covered by insurance companies for services provided in any but renal disease and in some incidences of diabetes.
I have hoped that our increased awareness of our flawed and extremely expensive health care system would lead to an increased emphasis on preventative health care where Dietitians can really have an impact. Unfortunately, the Centers for Medical and Medicaid Services (CMS) decided that it will cover screening and intensive behavior counseling for obesity (BMI > 30) ONLY by primary care providers in a physician’s office. It seems strange that they would authorize a higher billing fee by someone less qualified, but I guess the insanity continues. Here are some comments by other disappointed dietitians (source: Sports, Cardiovascular, and Wellness Nutrition Blog):
This is a call to action for all RDs! We need to interact on multiple levels with other providers and government officials to add us as providers for obesity care. We are 70,000+ strong and we are being denied the ability to bill for a service that we routinely provide. Enough with documentating outcomes. It’s time to descend on CMS with our outrage and concern that our inability to bill for this service will hinder the appropriate care of obese individuals. I wonder, would CMS expect MDs and NPs to perform and bill for physical therapy and not allow PTs to do so?
This decision is mind numbing. Clearly no logical argument will sway decision makers because logic isn’t being used to make these rulings.
I am pleased to see at any level that obesity is being viewed as an epidemic that needs qualified professionals to assist patients with this disease. I do believe that it will fail as without a complete team effort which includes the RD most patients will not get the education and direction they need on a one to one basis to make this trial program work. As amazing as doctors are they do not have the time to personally coach and support this disease. The behavioral therapist does not have a nutrition background to discuss specific meal plans for the patients with medical issues such as diabetes or heart disease. As a dietitian for over 20 years I have learned one thing. It takes a team to promote wellness. Each team member playing their part and not 2 team members trying to perform everyones role. This current trial period will not be successful in my opinion. And by the way, CMS better pay well. The therapists in my area charge between 150 to 350 dollars an hour and most do not want to accept any insurance at all for disordered eating behaviors.
Natalie Taylor said…
I am discouraged that the outcomes were based on weight loss vs. wellness/health outcomes (i.e. blood pressure, lipids, A1c, etc.). The obesity epidemic is an extremely complex issue involving hormones, genetics, environment, behavioral factors, coping skills, etc. I agree we need a team consisting of a physician, exercise physiologist, RD, and psychologist to have the best outcomes. However, I feel we should use the “Health At Every Size” approach (similar to Canada’s Vitality Program) and the focus should be placed on a healthy lifestyle/wellness/health and lab values vs. the number on the scale. Since the weight loss outcomes are extremely poor (i.e. 95% of people regain after 5 years) and the dangers of weight cycling are many (i.e. increased risk of mortality, gallbladder disease, high cholestorol, compulsive or deprivation-driven eating style, etc.), this program goes against the rule of “first do no harm”.
Marla Heller, MS, RD (marlahrd) said…
1. Where is the grade A or B evidence that primary care practitioners in a primary care setting can have successful outcomes?
2. When we have a critical shortage of primary care physicians and midlevels, why would we try to give them new time-consuming therapies? This is counterproductive for increasing the availability of primary care to the millions of Americans who need it.
3. Would anyone promote primary care physicians and midlevels to do respiratory therapy, physical therapy, occupational therapy, mental health counseling? Then why would we expect them to do medical nutrition therapy?
Jaimie Winkler, RD, LD said…
I am pretty appalled at this decision by medicare. Especially as the nutrition care process specifically highlights the behavioral modification strategies dietitians are expected to employ. I am curious about the training differences between those deemed to be qualified and the dietetic education that the CMS feels creates a distinction.
Nora Norback, MPH, RD, CDE said…
NOTE TO SELF:
- Align with PCPs in new ways
- Market to PCPSs and Medicare beneficiaries in new ways. (IDEAS??)
- Advocate for comprehensive and coordinated model of care, articulate what the RD can/will do.
- Create spreadsheet for with initial assessment (this is big!), triage options, and columns for re-assessing rx, clinical AND behavioral outcomes.
- Contact ADA to see if they have a spreadsheet to build upon. Might be nice for standardization if all RDs had it
- Most importantly, collect, report, and publish outcomes data to strengthen the foundation of clinical evidence used by CMS and others in making coverage decisions.”
It takes a village. Ranting and raging won’t win this. RDs ARE ahead of the curve in thinking this thru. MDs will need time to catch up. Ahh, aligning in new ways includes educating MDs on MNT.
I work in 2 Primary Care settings were MD’s, PA’s and NP’s routinely will refer Medicare patients for MNT for weight issues. I have offered patients without Diabetes or Renal Dx the option to see me under a fee for service structure, which in many cases they agree to pay. My ? is whether now that we could use the “incident to” criteria under Medicare, to bill for MNT for Obesity; can we switch to the “Incident to” designation depending on the diagnosis? I have not used the “Incident to” due to the fact that it appears as if the MD is providing the service and not the RD’s, and I feel strongly that we need to continue to make our services visible to the insurance companies. Any thoughts on my ? would be appreciated.
Life Focus Nutrition said…
The answer I got directly from the nutrition services coding team is the yes incident to MD services will be considered but more comments after a meeting last week in DC will be forthcoming. That does not help any of us who work outside of that business model, nor will provide evidence that our independent services and produce successful long term cost savings to the healthcare system.
As former coding and coverage chair this comes as a blow for all of us who have worked against this. I agree with all the above comments that we should be the front line providers. As I had shared to those involved in this outcome, would medicare suggest PT to be conducted strictly in an MD office by an MD?
I am involved in a program that truly assesses health risk based on clinical labs( BP,lipids, HgA1C, etc) and proven outcomes that go beyond the number on the scale independent of MD services. The MD driven business model continues to reduce our profession it “incidental.” Research demonstrates that RD’s could be the leaders for achieving lowered health care cost of all if given the tools to allow it! Linda Arpino, MA,RD,CDN