Dietitians celebrate National Nutrition Month in March, but instead of celebrating our incremental gains we should leverage our soap box to spotlight a huge fail: the dismal access to qualified nutrition counseling and medical nutrition therapy (MNT) in medicine today.
Americans are drowning in a sea of poor metabolic health. What we eat– and increasingly how food is grown–impacts the risk of most inflammatory conditions including diabetes, heart disease, gastrointestinal and autoimmune disease, even cancer. However, you would be hard pressed to prove it given current medical practice.
Today access to nutrition counseling remains underutilized, under appreciated, and inadequately reimbursed. In order to bridge the gap in conventional medicine beyond treating illness and injury, to effectively incorporate wellness/prevention, we need to fully integrate nutrition in health care.
DIETITIANS ONLY REIMBURSED TO TREAT DIABETES AND RENAL DISEASE
Dietitians help patients make significant improvements in their health, yet Medicare and most private insurance companies routinely reimburse patients only to treat diabetes and renal disease. They also typically limit access to between 2-3 hours of medical nutrition therapy. This is nuts. Can you imagine the outrage if doctors were only reimbursed to treat diabetics and renal patients before dialysis–and only for a couple of visits a year?
Over the years I’ve endured multiple insults from insurance company underwriters. In the early years I was informed that I was not a qualified provider. At times I was advised that nutrition counseling was just “education”. The most current insult reflects a strategy to limit access by limiting the number of approved providers.
Recently one insurance company refused to even consider an application to become a provider, explicitly stating that they had “enough” dietitians in the area. I called to apply when a new client told me that one of the dietitians offered on their provider list worked in San Dimas and the other in Simi Valley. My office is located in Santa Monica where the patient lives.
CAN WE DELIVER ADEQUATE NUTRITION SUPPORT?
Dietitians could and should be doing more, especially when it comes to addressing questions regarding food and nutrition. At the least, dietitians should be the primary health professionals delivering nutrition education. They should be consulted when others speak to nutrition issues because too many in the health care field speak about food and nutrition, and get it wrong.
Despite the best of intentions, physicians, nurses and other health care providers deliver simplistic directives and often speak in sound bites that do little impact patient behavior. I’ve touched on the subject regarding physicians before, but it seems most health care providers are willing to offer nutrition advice despite little to no formal education.
How problematic is the practice? Here are a few situations I’ve personally observed over time.
POOR NUTRITION ADVICE IN HEALTH CARE
- Nurse recommends 8 glasses of water a day to a chemotherapy patient, only to have patient experience nausea and vomiting due to too little sodium concentration in the blood, a condition known as hyponatremia. (It’s usually a good idea to assess a patient’s diet before offering specific dietary advice)
- Nurse purses her lips and looks pointedly at a pregnant woman and the scale noting her weight gain. No discussion. (Judgment without finding out more information isn’t helpful. Has shame ever been an effective agent of change?)
- Physician assistant tells patient that herbal tea is metabolized differently if it is in a capsule rather than consumed as a liquid (Uhmm, not likely)
- Nurse practitioner tells orthopedic patient that she should restrict all alcohol the week before surgery. (My research found one frequently quoted study regarding alcohol and surgery. Participants drinking 5 or more drinks a day experienced 200-400% more negative outcomes in surgery than those drinking 0-2 drinks per day. Consuming 3-4 drinks a day increased risks by 50%. Basically the study suggests it’s a good idea for alcoholics to get sober before surgery.)
- Pharmacist advises diabetics taking prednisone to watch their blood sugar (Prednisone and similar corticosteroids impact everyone’s glucose tolerance, not just diabetics. Why not suggest effective nutrition counseling to help all patients minimize the metabolic fallout and avoid blowing up like a balloon?)
- Nurse presents health education class to reduce risk of high cholesterol. No only was the manual out of date (printed 9 years before), but she couldn’t answer any specific nutrition question
- Physician tells patient to avoid peanut butter recommended by the dietitian because it is “fattening” (no single food is fattening, just as no single food helps you lose fat weight)
- Physician tells anorexic patient to avoid eggs because her serum cholesterol levels are elevated (dietary cholesterol is not the issue here–malnutrition is)
- Physician tells patient to eat more fiber because it helps the body to lose fat weight (it doesn’t quite work that way)
- Exercise Physiologist tells patient to exercise as hard as she can, as long as she can–despite evidence that she is insulin resistant and unable use fat effectively for fuel (she needs help improving her body’s ability to use fat for fuel, not make it worse)
- Exercise Physiologist tells spa guest recovering from bulemia that she should train harder because she has great potential (patient was recovering from history of compulsive exercise to purge after compulsively overeating. Big mistake)
LET’S STOP PRETENDING ALL HEALTH CARE WORKERS OFFER COST EFFECTIVE NUTRITION COUNSELING
Maybe we need to stop pretending everyone in health care should address concerns about food and nutrition. In addition, let’s stop pretending primary health care providers have the time, resources and or capacity to execute effective nutrition counseling. And let’s be smart about why.
Currently the Centers for Medicare and Medicaid policy allows primary care providers (PCP) to be reimbursed for providing counseling for obese Medicare patients. This is also the entity that limits access to dietitians for only two diagnosis. In every way these policies contribute to a nutritional- free-for-all in medical practice today.
In a climate of escalating health care costs and a looming scarcity of PCPs why do current policies directly and indirectly charge doctors, nurse practitioners, and physician assistants with the task of providing nutrition counseling?
In one paper I reviewed a family practice doctor’s time is valued at $48.33 per minute, a cardiologist at $90.28 per minute. Both nurse practitioners and physician assistants garner far more in salary than dietitians. Registered nurses are paid more as well. Using more expensive resources to provide inferior nutrition support makes no sense as all.
Dietitians and other qualified nutrition counselors are specifically educated and trained to provide patients personalized and effective nutrition support. Can someone explain why we aren’t using the best and most cost effective resource for the task at hand?
SIMPLE SOLUTIONS THAT SAVE MONEY, INCREASE EFFECTIVENESS, AND IMPROVE PATIENT OUTCOMES
Effective nutrition support reduces risk of disease, improves a patient’s ability to heal, and decreases negative side effects of treatment. Health care simply needs to adequately reimburse dietitians to realize these savings. Consumers and health care providers alike should press for change.
I’m outlining my top four priorities to get the conversation started, but if we have to go at this piece meal, start with #4 for the biggest impact of all.
- Medicare and private insurance companies should routinely reimburse medical nutrition therapy (MNT) by a dietitian or qualified nutrition consultant for all conditions linked with food choices, overall diet, and other lifestyle factors, not just diabetes and renal disease.
- Medicare and private insurance companies could consider reimbursing MNT in hospital settings, even if to only to initiate counseling and direct follow up for MNT in the outpatient setting. Currently medical nutrition therapy by the clinical dietitian is bundled with food service, housekeeping, and other basic services.
- Physicians should routinely refer to dietitians as a primary treatment to treat life style diseases –even before prescription drugs are offered (Knowing that MNT is a covered benefit would help)
- Reimburse nutrition counseling by dietitians and qualified nutritionists for women before, during and after pregnancy to turn this metabolic mess around.The Center for Medicare and Medicaid should encourage access to a dietitian in every outpatient setting, but to effectively turn the tide of escalating medical costs we need to focus on perinatal health. Epigenetic influences throughout pregnancy influence a child’s risk of disease for life, and the metabolic state of mom at conception is key.
I’m sure there are more dietary disaster stories to tell, and I’d love to know if there are medical models where dietitians are accessible and affordable to all patients. Feel free to share your experiences in the comments below.