June 22, 2018
Office of Management and Budget
Office of Information and Regulatory Affairs
Attention: CMS Desk Officer
Re: Info Collection: Medicare Current Beneficiary Survey (MCBS) -- Revision
Dear CMS Desk Officer,
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Centers for Medicare & Medicaid Services (CMS) at the United States Department of Health and Human Services (HHS) related to its May 23, 2018 information collection "Medicare Current Beneficiary Survey (MCBS) -- Revision." Representing more than 104,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States. Many RDNs independently provide professional services such as medical nutrition therapy (MNT) under Medicare Part B. The Academy supports the information collection and offers the following suggested content additions. Improved data utilization can substantially increase the quality of care delivered and improve outcomes for the expanding Medicare population.
The Academy supports the information collection and offers the following suggested content additions. Improved data utilization can substantially increase the quality of care delivered and improve outcomes for the expanding Medicare population.
A. Medicare in Context
Medicare has reimbursed providers for effective, quality services in acute care hospitals and skilled nursing facilities for millions of patients. However, in a noteworthy 2013 paper, Krumholz details how hospitalization is itself a risk factor for a range of adverse health consequences, including malnutrition.2 The author notes that the accumulated stress of hospitalization induces a post-hospital syndrome distinct from the original reason for admission and specifically notes that "physiological systems are impaired, physiological reserves are depleted and the body cannot effectively avoid or mitigate health threats."3 The syndrome emerges during hospitalization due to poor sleep and nourishment, altered circadian rhythms, pain, medications that can alter mental and physical function, and deconditioning due to bed rest, the latter of which can lead to diminished capacity to fulfill post-discharge recommendations and perform ADLs.4 Accordingly, survey questions should be more specifically designed to not only assess quality and access to care, but delineate, and potentially expand, the awareness of patients about clinically-appropriate methods to avoid or minimize hospitalization, as well as approaches to optimize health status upon discharge. Medical nutrition therapy (MNT) delivered by RDNs, whether in the community or clinical setting, is ideally-suited to this task. It is well established that nutrition therapy interventions are cost effective, and delay admission to high-expense acute care hospitals and long term care facilities.5
Patient awareness and education in this context is important, since many primary providers are apparently unclear about the role of MNT in chronic disease management.6 Thus, optimization of cost-effective health outcomes for chronic disease may be primarily dependent not on a provider recognition of the need for a referral, but on patient request for such a referral.
B. Survey Enhancement
The Academy offers the following suggested questions to support survey effectiveness and utility.
For the Community Component:
- Are you aware that Medicare covers the delivery of nutrition services by registered dietitian nutritionists for some conditions in the community setting?
- If these services would help delay or prevent chronic diseases and reduce your chances of being hospitalized or placed in a nursing home, would you consider seeing a registered dietitian nutritionist to help you understand how your food choices affect your health?
- How often does your primary physician discuss your eating patterns with you? a) each visit, b) more than half but not all visits, d) less than half, d) rarely, e) never.
- Has your primary physician offered to refer you to a registered dietitian nutritionist? a) frequently, , b) a few times, c) never
For the Facility Component (directed to staff)
- Are you aware that medical nutrition therapy provided by registered dietitian nutritionists can help your patients enhance recovery, reduce complications, maintain strength, and enhance ability to perform ADLs?
- How many of your patients do you think would be interested in seeing a registered dietitian nutritionist to help them understand how their food choices affect their condition(s)? a) all, b) most, c) some, d) a few, e) almost none or none
- How often do you discuss your patient's eating patterns with them? a) each visit, b) more than half but not all visits, d) less than half, d) rarely, e) never.
- How many patients have you offered to refer to a registered dietitian nutritionist? a) all, b) most, c) some, d) a few, e) almost none or none
- If the answer to the last question was c, d, or e, what are the primary obstacles to referral? a) perceived lack of patient interest, b) unclear about potential of MNT to help your patients, c) expected poor compliance, d) perceived cost issues, e) unaware of coverage for these service, f) difficulty finding an RDN in the area, g) doubted patients’ ability to change their lifestyle or h) other (please identify_____________________).
The Academy appreciates the opportunity to comment on the proposed information collection for the "Medicare Current Beneficiary Survey -- Revision" docket, and we appreciate your consideration. Please contact either Jeanne Blankenship at 312/899-1730 or by email at email@example.com or Mark Rifkin at 202/775-8277, ext. 6011 or by email at firstname.lastname@example.org with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Mark E. Rifkin, MS, RD, LDN
Consumer Protection and Regulation
Academy of Nutrition and Dietetics
1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 Krumholz, HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med. 2013 Jan 10;368(2):100-2.
5 Academy of Nutrition and Dietetics Evidence Analysis Library (EAL). "What is the evidence to support the cost-effectiveness, cost benefit, or economic savings of outpatient MNT services provided by an RD?" Accessed June 21, 2018.
6 Barnes PA, et al. Perceived factors influencing hospital-based primary care clinic referrals to community health medical nutrition therapy: An exploratory study. J Interprof Care. 2018 Mar;32(2):224-227.