In the recent decision memorandum by CMS regarding Intensive Behavioral Therapy for Obesity (CAG-00423N) the agency determined that potentially lifesaving preventive services for Obesity could only be furnished by primary care providers in the primary care setting. As a result, CMS has eliminated the most qualified providers, notably Registered Dietitians (RDs), along with clinical psychologists and other specialists who have been able to produce the best results for patients. The decision prevents this group from directly billing for services and from providing services outside of primary care, and limits access for older patients to qualified professionals that would help manage chronic disease.
Response to Petition
By Jonathan Blum
Thank you for your interest in helping Americans become and stay healthy through healthy eating. I am writing to respond to yourpetition asking CMS to reconsider its decision excluding Registered Dietitians from direct billing for Obesity Therapy.
Obesity is a serious problem in this country and worldwide. The Centers for Disease Control and Prevention (CDC) has reported that "obesity rates in the U.S. have increased dramatically over the last 30 years, and obesity is now epidemic in the United States" (Kahn, 2009). According to a 2010 study of health and nutrition, for adults 60 years and older, obesity exists in about 37% of men and 34% of women.
The Centers for Medicare & Medicaid Services (CMS) released a National Coverage Determination (NCD) on November 29, 2011 addressing intensive behavioral therapy for obesity in Medicare beneficiaries with a body mass index (BMI) of 30 kg/m2 or greater. The final decision memorandum states that coverage is limited to the primary care setting.
In response to public comments on the NCD urging that coverage be extended to services furnished by other types of practitioners including registered dieticians, CMS explained:
[W]e believe it is important that these preventive services should be furnished in a coordinated approach as part of a comprehensive prevention plan within the context of the patient's total health care. Primary care practitioners are characterized by their coordination of a patient's comprehensive healthcare needs. ... Other provider specialties may provide patient care in other settings but do not offer care in the context of being the coordinator of the patient's healthcare needs, not limited by problem origin or diagnosis. Coordination of health services is especially important in the presence of the coexisting health issues of our Medicare beneficiaries.
We understand that registered dieticians would like to provide and bill Medicare directly for intensive behavioral therapy for obesity. The decision memorandum provides background and explanation for the NCD including that Medicare coverage is modeled on the evidence-based recommendations of the United States Preventive Services Task Force (USPSTF). The USPSTF evidence review on treatment for obesity (on which their dietary counseling recommendation is based) is available here (.pdf).
In the public comment section of the decision memorandum, we further responded to comments requesting coverage for these services when furnished by non-primary care practitioners with the following language:
In the primary care office setting, Medicare may cover these services when billed by the primary care physician or practitioner and furnished by auxiliary personnel under the conditions specified under our regulation at 42 CFR section 410.26(b) (conditions for services and supplies incident to a physician's professional service).
As this language indicates, other "auxiliary personnel," which may include registered dietitians, are able to furnish intensive behavioral therapy for obesity services when provided in the primary care setting under the rules and conditions of existing Medicare regulations. The primary care physician or practitioner would need to submit the claim for billing.
We support the work of registered dietitians and recognize their valuable contribution to our society. We will continue to collaborate with all clinicians and groups who want to help us combat the obesity epidemic in our Nation, and continue to consider this policy in the future.
Jonathan Blum is Deputy Administrator and Director for the Center of Medicare, Centers for Medicare and Medicaid Services