by
Phil Galewitz, Kaiser Health News | Sep 9,
2019 3:39pm
Louis Rocco has lived with diabetes for
decades. But until he met with a registered dietitian in August, he
didn’t know eating too much bread was dangerous for him.
“I’m Italian, and I always eat a lot of
bread,” he said. After two hourlong visits with a dietitian—including a session
at his local grocery store in Philadelphia—Rocco, 90, has noticed a difference
in his health.
“It’s helped bring down my sugar readings,” he
said of changes in his diet including eating less bread. “I wish I knew I could
have had this help years ago.”
After getting a referral this summer from his
doctor, Rocco learned that Medicare covers personal nutritional counseling for
people with diabetes or kidney disease.
The estimated 15 million Medicare enrollees
with diabetes or chronic kidney disease are eligible for the benefit, but the
federal health insurance program for people 65 and older and some people with
disabilities paid for only about 100,000 recipients to get the counseling in
2017, the latest year billing data are available. The data do not include
the 20 million enrollees in private
Medicare Advantage plans.
Health experts say the little-used benefit
represents a lost opportunity for beneficiaries to improve their health—and for
the program to save money
(PDF) by preventing costly complications from the diseases.
An estimated 1 in 4 people 65
and older have diabetes and 1 in 3 have
chronic kidney disease. Kidney disease is often a complication of diabetes.
The prevalence of diabetes has risen markedly
(PDF) in the past 20 years, and the condition is more common as people age.
Nationwide, there are 100,000 registered dietitians—more than
enough to meet demand, said Krista Yoder Latortue, executive director of Family
Food in Philadelphia, which employs about 50 dietitians including the one who
visited Rocco. Medicare data showed about 3,500 dietitians billed the program
for nutritional counseling in 2017.
The problem may be that not enough physicians
know about the Medicare benefit. Doctors have to refer patients to a dietitian.
Congress approved the benefit, which began in
2002, after studies found medical nutrition
counseling leads to improved health outcomes and fewer complications for older
patients. Under the preventive health provisions of the Affordable Care Act,
the counseling has been available without out-of-pocket costs to Medicare
beneficiaries since 2011.
Medicare pays for three hours of dietary
counseling during the first year the benefit is used and two hours in subsequent
years. A doctor can appeal to Medicare for additional nutritional therapy if
the physician believes it is medically necessary.
Larry Lipman, 70, of Falls Church, Virginia,
said he was shocked to learn he had diabetes earlier this year because he’s
relatively thin and is an avid cyclist.
When his doctor recommended meeting with a
dietitian, he not only said yes but also brought along his wife, who does most
of the cooking.
“It was great because I could ask specific
questions and get into the nitty-gritty about how I eat, what I eat and when I
eat,” said Lipman, a retired journalist.
“I’ve learned I needed to cut down on portion
sizes of rice and other things to keep my carbohydrates down,” he said. “I’m
thinking more about what I eat every time and staying away from Doritos and ice
cream.”
Doctors shoulder some of the blame for
patients not getting dietary counseling by failing to refer them to dietitians.
“It’s a lot easier to prescribe a medication
than it is to discuss the importance of nutrition and get patients to meet with
a registered dietitian,” said Dr. Holly Kramer, a Chicago nephrologist and
president of the National Kidney Foundation.
“I don’t understand how we have this
burgeoning obesity and diabetes epidemic and we are not using dietitians in our
clinics for all these patients, yet we are paying for all these things that
mediate from the disease process such as arthritis, dialysis and amputations,”
she said.
Jennifer Weis, a registered dietitian in
Philadelphia, said the limited hours Medicare covers is frustrating given how
difficult it is to change behaviors in older adults.
“It’s better than nothing, but in my mind is
not sufficient,” she said.
Doctors might not be aware of the Medicare
option, since “it’s a challenge to keep up with what is a covered benefit and what
is not,” said Dr. Michael Munger, chairman of the American Academy of Family
Physicians who practices in Overland Park, Kansas. He said many doctors who
don’t practice with a large health system may not be familiar with dietitians
in their community.
For convenience, Munger said, he refers his
diabetes patients to a nurse practitioner in his office for nutritional
counseling. But only registered dietitians are covered under the Medicare
benefit, so his Medicare patients face a copayment for that service.
Nutritional counseling is not the only
underused Medicare benefit that can prevent health complications.
Fewer than 5% of Medicare beneficiaries
(PDF) use their 10 to 12 hours of diabetes self-management
training benefit, which can cover individual and group sessions
providing tips for eating healthily, being active, monitoring blood sugar,
taking drugs and reducing risks.
Part of the problem, said Yoder Latortue in
Philadelphia, is there is a lot of misinformation about whom the public can
trust on nutrition advice.
“Everyone eats and everyone has an opinion,”
Yoder Latortue said.
Lauri Wright, a Jacksonville, Florida,
registered dietitian and spokeswoman for the Academy of Nutrition and
Dietetics, said the federal Centers for Medicare & Medicaid Services (CMS)
sends out notices to health providers once a year, but more information is
needed.
About 10,600 registered dietitians have
enrolled to treat Medicare patients, a CMS spokeswoman said. She said the
agency has been advising health providers about the benefit and promoting it to
enrollees on its website and its annual handbook that it sends to
beneficiaries.
Still, “I think because only two diseases are
covered by Medicare and the rest aren’t, it falls off everybody’s radar,”
Wright said.
Kaiser Health News is a nonprofit
news service covering health issues. It is an editorially independent program
of the Kaiser Family Foundation, which is not affiliated with Kaiser
Permanente.
No comments:
Post a Comment