Medicare Chooses Inferior Care for Obesity

Preventing dietitians from becoming providers for obesity care is not in the best interest of patients 

I received some good news the other day. Medicare has agreed to cover Intensive Behavioral Counseling for Obesity for eligible Medicare beneficiaries. And then I read the statement released by the Centers for Medicare & Medicaid Services (CMS). Registered dietitians and psychologists will be excluded as obesity care providers. According to CMS obesity counseling must be provided by a “qualified primary care physician or other primary care practitioner and in a primary care setting.” What does this mean? A "qualified primary care physician", according to the Social Security Act is a physician who is a general practitioner, family practice practitioner, general internist or obstetrician or gynecologist. A “primary care practitioner” is defined as a physician with a primary specialty of family medicine, internal medicine, geriatric medicine or pediatric medicine or a nurse practitioner, clinical nurse specialist, or physician assistant." Obesity services must be provided in a primary care setting which CMS defines “as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities and hospices are not considered primary care settings under this definition.”


The bottom-line is that registered dietitians who are highly trained to intensively counsel obese individuals will not be allowed to bill Medicare for obesity intervention and private nutrition practices that are established and operated by dietitians are not considered an appropriate setting by CMS for nutrition education of these individuals.

I cannot say for certain what was really behind the decision to exclude dietitians from becoming Medicare providers for obesity counseling because Medicare's explanations seem lame to me. The American Dietetic Association described CMS's action with regards to the exclusion of dietitians as follows:

  it appears that CMS excluded RDs for two reasons:

1. CMS believes it lacks the statutory authority to include RDs as providers outside of diabetes and end stage renal disease; and

2. CMS believes it is important that preventive services be furnished in a coordinated approach as part of a comprehensive prevention plan within the context of the patient’s total health care. As such, they believe primary care practitioners are best qualified to offer care in this context.

Apparently Congress has not charged dietitians in the fight against obesity but dietitians are allowed to help people with diabetes and end stage renal disease. Many people with diabetes are obese and when I am counseling them for diabetes management, weight management is always a part of the intervention.

As for "preventive services being furnished in a coordinated approach as part of a comprehensive prevention plan within the context of the patient's total health care," what Medicare fails to see is that it doesn't matter how well care is coordinated if it is inadequate. To date primary care intensive obesity intervention consists of MDs and NPs telling patients that they need to lose weight and referring them to a dietitian. Now that MDs and NPs will be able to bill for counseling for obesity they can remove the dietitian from the equation and bill their services at a much higher rate than the RD would bill and provide less than adequate nutrition counseling possibly after attending a weekend course on obesity management to supplement their one medical scool course in nutrition. I don't mean to disparage doctors, but they are not trained to provide comprehensive nutritional intervention. My husband is a physician and he is the first to admit that most doctor's knowledge about nutrition is lacking. Think about it this way, does Medicare require that physical therapy be provided under the primary care physician's watchful gaze in a primary care setting?

I am always dismayed when I read press releases about new scientific discoveries related to obesity in which the final sentence in the release states that this information can be used to develop a drug to combat obesity. Obesity fighting drugs that have already been released are often recalled because they pose a serious risk to health and can cause death. Humans have existed for thousands of years with minimal obesity until now. We know how to combat obesity and it is not a pill. It is inexpensive but labor intensive and it does not make research and drug companies incredibly wealthy.

A cynical interpretation of this whole debacle is that lobbying from Big Pharma helped to ensure that the practitioners who can prescribe medications would be the only ones whose obesity related services could be covered by Medicare.

It is sad to me that some highly qualified nutrition and behavioral therapists (dietitians and psychologists) will be excluded from treating Medicare recipients. Patients who want to see dietitians and psychologists for nutrition and behavioral counseling will have to pay for these services out of their own pockets (again).

What do you think? Will Medicare provide the most comprehensive treatment for obesity by the most qualified providers?