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Medicare could pay for nutrition therapy by R.Ph.s

The Centers for Medicare & Medicaid Services (CMS) has expanded coverage for medical nutrition therapy. MNT is now a covered benefit for Medicare patients with diabetes or renal disease, even if the patients are also receiving benefits for diabetes self-management training.

Registered dietitians or other practitioners with equivalent training can get their own Medicare provider numbers. That means qualified nutrition practitioners can receive assigned benefits directly instead of working through a physician's provider number.

That's the good news, said Jay Mirtallo, a nutrition support pharmacist at Ohio State University Medical Center. The bad news is that he knows of only one pharmacist who is also a registered dietitian, the sole healthcare profession CMS has designated to provide MNT.

"The exciting thing is that CMS has finally recognized that healthcare professionals other than physicians can provide an impact on patient care and get paid on his/her own account," he said. "Our sister profession has done the hard work up front and shown us the way to go to obtain our own recognition." Mirtallo is also director of advocacy for ASPEN, the American Society for Parenteral and Enteral Nutrition.

The new Medicare MNT benefit was created by the Medicare, Medicaid, and SCHIP Benefits Improvement & Protection Act of 2000 (BIPA). Under prior law, nutrition counseling was covered only as a part of other benefits, such as an inpatient hospital stay.

"This [new benefit] is very important for diabetics because of their problems with metabolizing carbohydrates, and for patients with renal disease for eliminating proteins from the body," said Jeffrey Kang, M.D., director of the CMS office of clinical standards and quality. "Both conditions cause damage to other parts of the body if not controlled."

Medical nutrition therapy is one of the few preventative services covered as a Medicare benefit. Congress approved Medicare's first preventative service, pneumococcal pneumonia vaccine, in 1980. In 1997, lawmakers added the diabetes self-management training benefit as part of the Balanced Budget Act. BBA also required the Department of Health & Human Services to consider coverage for skin cancer screening, certain dental services, elimination of time restrictions on immunosuppressive drugs for transplant patients, coverage of clinical trials, and nutrition therapy. Cost-benefit analyses were to be conducted by the Institute of Medicine (IOM).

The MNT benefit change is a direct result of an IOM report issued in 2000. "The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population" noted that poor nutrition is a major problem in older Americans. The vast majority of seniors have chronic conditions in which nutrition interventions have a demonstrated impact on health status and quality of life.

Of older Americans, 87% have diabetes, hypertension, dyslipidemia, or a combination of these diseases. All have potentially adverse outcomes that can be ameliorated or reduced by nutrition intervention, but nutrition therapy was not a covered benefit for most Medicare beneficiaries.

The most direct solution: Create a new nutrition-therapy benefit. Depending on utilization, the IOM estimated costs for the new benefit at somewhere between $873 million and $2.63 billion for the five years from 2000 to 2004. The report also estimated savings of up to $330 million for diabetes patients alone.

The new benefit, the IOM said, should be delivered by registered dietitians, "currently the single identifiable group with standardized education, clinical training, continuing education, and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy."

That doesn't help pharmacists directly, Mirtallo said. But the IOM left an open invitation to other healthcare professions to submit evidence showing that they, too, have a demonstrable impact on patient outcomes.

"Registered dietitians are the gold standard," he said. "As pharmacists, we need to provide the same kinds of outcomes data on pharmacy's contributions to patient care. Pharmacists with a BPS certification in nutrition support may be the best situated to show that we fill a similar professional role."

Educating CMS on pharmacy and nutrition could take years, Mirtallo said. Nutrition support pharmacists who don't want to wait may be able to obtain Medicare provider status more quickly.

Many states do not have a specific dietetic practice act, he explained, a problem that CMS has recognized. In states that do not license or certify dietitians, pharmacists and other practitioners with equivalent training and experience can also obtain MNT provider numbers. A CMS spokeswoman confirmed that, in these states, if a pharmacist has a degree in an "appropriate" subject plus 900 hours of supervised professional practice in nutrition, he could apply for a Medicare provider number and get paid for services rendered.

Fred Gebhart

Fred Gebhart. Medicare could pay for nutrition therapy by R.Ph.s.

Drug Topics

2002;8:HSE44.