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Dietitians Using Medicare Reform to Monopolize Hospital Nutrition Services

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Girl-eating-hospital-food-002It won’t help hospital food, already notoriously bad, to outlaw advice from the most qualified nutritionists. Action Alert!

Medicare claims to be reforming some of its rules in order to get rid of unnecessary or burdensome regulations. But this has created a window for the dietetics lobby to insert language that will give them a monopoly over hospital diets. This is the very definition of a sneaky maneuver—almost no one would think to look for this change until it had already passed. Happily, we did!

The Federal Register announced the various reforms to Centers for Medicare and Medicaid Services (CMS) rules earlier this month. Buried deep inside the new regulations are two sections: Food and Dietetic Services and Privileges for Registered Dietitians (RDs). This would revise the requirement that a therapeutic diet be prescribed only by the practitioners responsible for the care of the patient—a revision we agree with, since few physicians know anything about nutrition. But it would be expanded to include only Registered Dietitians (not Certified Nutrition Specialists, many with Master’s degrees and PhDs, or other highly qualified nutrition professionals) to prescribe a therapeutic diet. This rule specifically deals with special diets for patients; RDs already have a grip of iron on regular hospital food—though not by law!

CMS writes—though it could very easily be the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) talking—“We believe that RDs are the professionals who are best qualified to assess a patient’s nutritional status and to design and implement a nutritional treatment plan.” It adds that RDs with prescription privileges “would also be able to provide medical nutrition therapy and other nutrition services at lower costs than physicians as well [sic].” Note the co-opting of the terms “medical nutrition therapy” and “nutrition services” for RDs, even though RD’s are only required to have a college degree, and the tortured government logic that creating a new monopoly will reduce costs.

The US Department of Labor places hospital diets under the control of both dietitians and nutritionists. Medicare rules should follow the same guidelines.

Securing a piece of the Medicare pie is part of the dietitians’ strategy at the state level as well. Medical nutrition therapy (MNT) services are covered under Medicare part B for people with diabetes. Federal rules state that RDs or qualified nutrition professionals may provide services so long as they meet certain education and experience requirements and have been certified by a national nutrition organization. However, if an individual state has a licensure policy in place, then only the licensed individual can receive reimbursement. That is why RDs are trying to get the states to pass laws making dietitians the exclusive providers of licensed nutrition services—it creates a separate tier for themselves so they can secure MNT reimbursement through Medicare.

The folks at AND/ADA are speaking out of both sides of their mouth about licensure. On one hand, they say they need a monopoly on scope-of-practice laws so they can be reimbursed by Medicaid and Medicare. But in the document that they submitted to CMS, they argue that “licensure is not a federal requirement” for dietitians to be part of a “medical staff” and therefore receive CMS reimbursement:

Licensure is not a federal requirement; it is only required for practitioners in those states with laws requiring licensure. Federal regulations specific to dietitians similarly have no independent licensure requirement. In section 482.28(a)(2) of the hospital [Conditions of Participation] defining a “qualified dietitian” in the hospital setting, “[q]ualification is determined on the basis of education, experience, specialized training, State licensure or registration when applicable, and maintaining professional standards of practice.”

Sorry, dietitians, you can’t have it both ways!

Here are the monopolistic licensure bills currently in state legislatures:

  • Indiana: HB 1272. We recently sent special action alert to Indiana residents about this.
  • West Virginia: HB 2533. We will be emailing a special action alert to WV citizens soon.
  • New Jersey: AB 2182/ SB 833. The bills are still “alive” but in a holding pattern.
  • In Illinois the law is much improved. We were able to get the Illinois legislature to replace the state’s ten-year-old monopolistic dietitian law to include certified nutritionists. The new law is currently in the rule-writing phase. We will keep you updated.

Action Alert! CMS is asking for public comments on the new Medicare rule. Tell them that while we agree that hospital diets should be open to nutrition professionals and not solely under purview of physicians, we cannot support Medicare rules that create a monopoly for RDs at the expense of often better-qualified nutrition professionals. Send your message today!

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