Registered Dietitians Have Limited Role in Obesity Counseling for Medicare.

Just this July, The American Association of Clinical Endocrinologists (AACE) said that there was “significant clinical evidence to declare obesity as a disease state”. At their directors meeting ,“ the Association believed that the declaration would help lead the way for more effective therapies and treatments to help the 34 percent of Americans currently suffering with obesity” (1). The co-morbidities of obesity are clear and have been for decades: with obesity there is higher incidence of hypertension, diabetes, cancer, heart disease and stroke. These diseases include the leading causes of death in the United States today. Moreover, obesity related diseases do not exclude our aging population of which the continuing obesity epidemic (15 million adults over age 51) signals a likely expansion in the population with obesity-related co-morbidities (2). Not only does obesity affect an individuals quality of life but health care costs are predicted to skyrocket-dare I say- out of control. Specifically, if the percentage of obese adults doesn’t change but stays at the current rate of 34%, then excess weight will cost the nation about $198 billion by 2018 (3).

Aging Population

Just two days ago, The Centers for Medicare and Medicaid Services (CMS) decided to cover screening and behavioral counseling for obesity. As Registered Dietitians (R.D.), your “nutrition experts”, this is music to our ears- coverage for obesity counseling for Medicare patients? Specifically, 4 clinic visits the first month, 8 visits for the next 4 months there after and then another 6 visits for the remaining 6 months. An entire year of coverage to help those eligible for Medicare to lose weight! Too good to be true? I’m afraid so.

The Registered Dietitian is not defined as the “primary care practitioner” so cannot provide Medicare patients with the intensive behavioral counseling for obesity in which dietitians have been schooled (many R.D.s have graduate and post graduate nutrition and counseling degrees) and all R.D.s have specialized training via rigorous academic internships. Instead physicians, nurse practitioners and physician assistants may provide behavioral obesity counseling to Medicare patients. How did this happen? The CMS is the decision making body not Congress. The American Academy of Nutrition and Dietetics has been involved in trying to help the R.D. ( to no avail because -this is the present deal.
1. The physicians can refer to Registered Dietitians but there is no Medicare coverage for that patient seeing the R.D..
2. The R.D. must be physically in the “primary care setting” with direct physician supervision – in other words, the physician needs to be physically in the same medical suite as the dietitian- then the dietitian gets to bill under the physician using “incident to” service codes.

This is a sad day for the Registered Dietitian …Your Nutrition Expert. We have been trained as the “go to provider” for intensive behavioral counseling for obesity but we cannot easily help our patients. We as entrepreneurs outside of the clinical primary care setting have the ability to reach hundreds and thousands of Medicare patients but it is today that the music stops playing.

1. American Association of Clinical Endocrinologists: July 28, 2011.
2. Forecasting the obesity epidemic in the aging U.S. population, Wang YC, Colditz GA, Kuntz KM , Department of Health Policy Management , Columbia Mailman School of Public Health,
3. Rising Obesity will cost US health care 344 billion per year by Nanci Hellmich, USA Today Health and Behavior , 11/17/09.