Academy Comments to Veterans Administration re Qualified Practitioners in the Veterans Choice Program

July 26, 2016

Brian McCarthy
Office of Regulatory and Administrative Affairs
Veterans Health Administration (10B4)
Department of Veterans Affairs
810 Vermont Avenue NW.
Washington, DC 20420

Re: Expanded Access to Non-VA Care Through the Veterans Choice Program (OMB Control No. 2900-0823)

Dear Mr. McCarthy,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Department of Veterans Affairs (VA) regarding its May 27, 2016 proposed information collection "Expanded Access to Non-VA Care Through the Veterans Choice Program" (OMB Control No. 2900-0823). Representing over 100,000 registered dietitian nutritionists (RDNs),1 nutrition dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. Every day we work with Americans in all walks of life — from prenatal care through end of life care — providing nutrition care services and conducting nutrition research, including providing care for veterans at VA hospitals and other facilities.

If the VA is to be assured that providers of nutrition care services maintain at least the same or similar credentials and licenses as those required of the VA's nutrition care providers, it can only do so by requiring the provider holds the registered dietitian nutritionist credential instead of (or in addition to) a state license as a licensed dietitian nutritionist.

Registered dietitian nutritionists have been identified as the most qualified food and nutrition experts, according to the Institute of Medicine (IOM), most physicians,2 and the US Preventive Services Task Force (USPSTF). In addition, RDNs provide nutrition care with better outcomes at a lower cost than physicians, nurse practitioners, and physician assistants. In fact, according to the prestigious National Academy of Medicine (formerly the Institute of Medicine), "the registered dietitian is currently the single identifiable group of health-care professionals with standardized education, clinical training, continuing education and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy."3

Although many RDNs are also licensed in their respective states, most states set the licensure standard at a minimum level that does not guarantee an individual is sufficiently qualified to work for the VA. Not all "licensed dietitian nutritionists" are "registered dietitian nutritionists," because becoming a registered dietitian requires a particularly rigorous internship with both programmatic and institutional accreditation that states do not typically require. Even a cursory review of the coursework required to attain some of the degrees and credentials deemed satisfactory for licensure as a nutritionist or dietitian nutritionist in some states makes clear that they are manifestly insufficient to assure the individual has the necessary competencies and skills to provide complex medical nutrition therapy for patients dealing with complicated, multifactorial diseases. Many programs require no training in nutrition counseling or medical nutrition therapy at all.4,5,6 Programmatic accreditation (not just accreditation of the school itself) verifies the content and quality of academic programs and ensures that graduates have received the knowledge preparing them to practice the profession with competence.

State licensure by itself is also insufficient to provide nutrition care services as a Medicare provider. To be eligible for reimbursement under Medicare (in addition to other requirements), a nutrition professional must have obtained "a baccalaureate or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics, as accredited by an appropriate national accreditation organization recognized by the Secretary for this purpose."7 The Accreditation Council for Education in Nutrition and Dietetics (ACEND), the accrediting agency for the Academy, meets this high standard and has been recognized by the Secretary of Health and Human Services as an appropriate organization. The Academy is unaware of other nutrition organizations recognized by the Secretary with the authority to accredit academic programs.

Problems with licensure among the states arise from the fact that there is variation among the standard qualifications for nutritionists and dietitians in many (but not all) licensure statutes. Alaska, Kentucky, Montana, North Dakota, Washington, and several other states have licensure or certification requirements for individuals that they license as a "nutritionist" that fall far below the federal standard for the "registered dietitian or nutrition professional" as codified in the Social Security Act.8 This difference in standards could increase risk for harm to consumers by potentially authorizing unqualified practitioners to provide Medical Nutrition Therapy (MNT) and nutrition counseling who have taken as few as three nutrition courses in subjects such as “nutrient depletion & drug/herb interactions” or "dietary supplements."9 These courses are manifestly insufficient in providing enough training for practitioners to practice MNT.

The Academy is proud of the work it has done to develop a strong academic and experiential framework that ensures RDNs have necessary competencies to provide safe, effective nutrition care services. We value our partnerships with states that protect consumers by regulating the profession and federal agencies that recognize the value of the RDN in their regulations.

Thank you for the opportunity to comment on the proposed information collection regarding the Veterans Access, Choice, and Accountability Act of 2014. We would be grateful for the opportunity to discuss these recommendations in greater detail in the near future with you. Please contact either Jeanne Blankenship at 312-899-1730 or by email at jblankenship@eatright.org or Pepin Tuma at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
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 Bleich SN, Bennett WL, Gudzune KA, Cooper LA. National survey of US primary care physicians' perspectives about causes of obesity and solutions to improve care. BMJ Open 2012:2:e001871. doi:10.1136/bmjopen-2012-001871.

3 Committee on Nutrition Services for Medicare Beneficiaries. "The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population." Washington, DC: Food and Nutrition Board, Institute of Medicine; January 1, 2000 (published).

4 One may obtain the Certified Clinical Nutritionist credential after online coursework from a non-regionally accredited institution with as little as an Associate's degree and without ever taking a course in nutrition counseling, medical nutrition therapy, or nutrition assessment—the very core of the licensed dietitian nutritionist scope of practice. http://www.cncb.org/CORE%20ACADEMIC%20REQUIREMENTS-2011.pdf

5 "Nutrition and Functional Medicine" degree: The University of the Western States will be offering an on-line Master's degree in Nutrition and Functional Medicine. There appears to be minimal requirements addressing MNT, and no counseling courses required. A "Nutrition through the Lifecycle" course and a course addressing metabolic syndrome and hypertension are only electives and are not required. http://www.uws.edu/Academic_Programs/MS_Nutrition_and_Functional_Medicine.aspx

6 "Nutrition Science" degree: North Carolina State University Raleigh has a Nutrition Science Program that does not require medical nutrition therapy or counseling courses. http://oucc.ncsu.edu/semester-display/CALS-11NTSBS-nosubplan-2101

7 42 U.S.C. 1395(vv)(2)

8 42 U.S.C. 1395(vv)(2) ("[T]he term 'registered dietitian or nutrition professional' means an individual who—
(A) holds a baccalaureate or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics, as accredited by an appropriate national accreditation organization recognized by the Secretary for this purpose;
(B) has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and
(C)(i) is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed; or
(ii) in the case of an individual in a State that does not provide for such licensure or certification, meets such other criteria as the Secretary establishes.

9 See, "Eligibility Requirements for the Certified Nutrition Specialist (CNS) Credential," upon which "nutritionist" licensure is typically predicated. Accessed January 4, 2013.