CMS PROPOSES ANTICOMPETITIVE MEDICAL NUTRITION THERAPY NICHE FOR RDs
Recommending the right nutrition for hospitalized patients requires a sophisticated understanding of biochemistry, pharmacology, and nutrition science. Registered Dietitians (RDs) have a bachelor of science degree and are granted that credential upon passing an exam that has few questions that probe the depth of one’s knowledge in the critical field of medical nutrition therapy. Consequently, except for those RDs with educational achievements beyond the bachelor’s level or acumen otherwise obtained in study of these hard sciences, it is a stretch, to say the least, for one to conclude that the typical RD is qualified to prescribe nutrition as a therapy for disease.
Nevertheless, the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) is a very aggressive guild. It lobbies diligently in every state in an effort to enact licensure regimes that exclude from the practice of dietetics and nutrition all but its own members. That anti-competitive zeal has led several states to make the guild an exclusive one in those fields to the detriment of consumers who might otherwise be edified and helped by nutrition counseling from people holding Ph.D.s in nutrition science, biochemistry, pharmacology or other related scientific fields yet who lack the RD credential.
On February 7, 2013, the Center for Medicare and Medicaid Services (CMS) published a proposed rule in the Federal Register, 78 Fed. Reg. 9216 (Feb. 7, 2013). The proposed rule would do much to make RDs the exclusive providers of medical nutrition therapy in our nation’s hospitals. The proposed rule includes a recommended revision to Section 482.28 of 42 CFR Part 482 concerning Food and Dietetic Services. At present, the rule requires a therapeutic diet to be prescribed only by the practitioners treating the patient (ordinarly M.D.s, D.O.s, APRNs, or PAs). Under the proposed revision, registered dietitians would be permitted addition to assume that role, such that they will be able to prescribe medical nutrition therapy to patients independent of attending physicians.
That prospect sends shivers down the spines of many conscientious physicians and experts in clinical nutrition. The thought that people with no more than a bachelor’s degree and little relevant experience in the science of human nutrition and biochemistry would be determining how best to treat patients in need of nutrition therapy offends their sensibilities.
The proposed rule includes braggadocio in favor of the guild, stating: “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 in consultation with the patient’s interdisciplinary care team.” Indeed, CMS goes on: “the RD must be viewed as an integral member of the hospital interdisciplinary care team, one who, as the team’s clinical nutrition expert, is responsible for a patient’s nutritional diagnosis and treatment in light of the patient’s medical diagnosis.”
Rather than open the door to competent, graduate level nutrition experts in prescribing therapeutic diets for those in the hospital, this rule proposes an anti-competitive niche for dietitians to assume that role to the exclusion of others. At least three major problems arise from this proposed revision.
First, as explained above, the RD credential is not an affirmation that the holder of the credential is a “clinical nutrition expert” if by that term we mean individuals qualified by education, training, and experience to diagnose the peculiar nutritional needs of individuals suffering from ailments, being treated with drugs, or recovering from surgery. The CMS proposed rule thus invites individuals who may not be qualified to make nutritional therapy prescriptions. For sure, some RDs also possess Ph.D.s or other graduate level degrees in relevant areas of science, but the fact that they have an RD is not in and of itself sufficient to prove they possess a knowledge basis sufficient to prescribe nutritional therapy. As most of us know, RDs are often involved in food service functions within hospitals and are rarely permitted to make basic diagnosis decisions nor should they, given what is usually a paucity of scientific training.
Second, there are many individuals who possess graduate level degrees in clinical nutrition, nutrition science, and related fields. They are ordinarily far better qualified to evaluate the often complex biochemistry associated with clinical nutrition in the hospital setting. Those individuals include the people who have been certified as nutrition specialists by the Certification Board for Nutrition Specialists. I am a member of the board of directors of that organization. To be eligible for the CNS credential, a person must not only possess a graduate level degree in clinical nutrition, nutrition science, or a related biomedical field, he or she must also have extensive experience in the appropriate settings, and pass a rigorous exam that is a detailed assessment of acumen in areas of biochemistry, biology, pharmacology, and nutrition science directly germane to the clinical nutrition profession.
Third, if this CMS rule is adopted as proposed, it will have the perverse effect of locking out of medical nutrition therapy a large universe of people who do not possess the RD credential but who are exceedingly well qualified to opine on such matters. That will be to the detriment, perhaps the grave detriment, of patients. Rather than improve the quality and degree of care afforded, the proposed rule locks in substandard care and reinforces an RD guild inside the nation’s hospitals.
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CMS claims that its proposed rule will help reduce the costs of medical care and improve the quality of care for hospitalized patients by providing RDs the opportunity to make nutrition prescriptions independent of physicians, physician assistants, and nurses. Ironically, by inviting those who may lack essential education and experience the opportunity to make such prescriptions, errors may occur which could increase the need for care, complicate the prognosis of patients, and increase the costs associated with hospitalization.
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