Academy Suggests AHRQ Survey of Consumer Satisfaction Include Referral Question

June 13, 2019

1600 Research Blvd.
RB 1186S
Rockville, MD 20850

Re: Consumer Assessment of Healthcare Providers and Systems Health Plan Survey 5.0 (Docket Number 2019-09855)

Dear Sir or Madam:

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit these comments to the Agency for Healthcare Research and Quality's May 14, 2019 request for information, "Consumer Assessment of Healthcare Providers and Systems Health Plan Survey 5.0." 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 world and is committed to a vision of the world where all people thrive through the transformative power of food and nutrition and related support systems. Every day we work with Americans in all walks of life — from prenatal care through end of life care — providing a variety of nutrition care services, including outpatient and ambulatory care.

The Academy strongly supports the efforts of AHRQ to conduct surveys to "assess patients' experiences with health care providers … and with health plans." Health plan coverage and limits determine to a large degree access to care for the lifestyle-related chronic diseases adversely affecting most Americans. Thus, we suggest that the survey measure whether and to what degree health plans ensure access to specialists who can help patients reduce disease risk factors and progression.

Research confirms that nutrition-related conditions represent at least 25% of the need for primary care visits, yet physicians may not be providing nutrition services for several reasons, including limitations on nutrition resources, counseling skills, available time, and reimbursement.2 Data on demand for nutrition services are not clear, but the prevalence of overweight (including obesity) in excess of 71%3 and the fact that Americans take an average of 11.5 medications annually,4 support the need for increased access to and delivery of quality nutrition care services that can improve weight status, health status, and reduce use of pharmaceuticals for certain nutrition-related disease states and conditions.

While much of primary health care for chronic conditions is reliant on pharmacotherapy, medical nutrition therapy has been shown to be highly effective in reducing costs while improving outcomes for patients with obesity, diabetes, and lipid disorders.5 Reducing medication usage also enhances the potential to reduce the over-80 million adverse events experienced annually by patients using prescriptions.6 It is also estimated that 128,000 hospitalized patients die annually due to properly-prescribed medications.7 Thus, pharmaceutical-related mortality could constitute the sixth leading cause of death in the United States.8 Accordingly, patient outcomes are most likely to be optimized by redirecting patient care for nutrition-related conditions toward nutrition services, as clinically appropriate.

Therefore, the Academy recommends that the CAHPS 5.0 survey include the following question: Was the respondent referred to a specialist or provided other resources for treatment of one or more chronic diseases that would benefit from a nutrition intervention?

The Academy appreciates the opportunity to comment on the "Consumer Assessment of Healthcare Providers and Systems Health Plan Survey 5.0" docket. Please contact either Jeanne Blankenship at 312/899-1730 or by email at or Mark Rifkin at 202/775-8277, ext. 6011 or by email at with any questions or requests for additional information.

Jeanne Blankenship, MS, RDN
Vice President
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 Kolasa KM, Rickett K. Barriers to providing nutrition counseling cited by physicians: a survey of primary care practitioners. Nutr Clin Pract. 2010 Oct;25(5):502-9.

3 "Obesity and Overweight." CDC National Center for Health Statistics.

4 "Retail Prescription Drugs Filled at Pharmacies per Capita." Henry J. Kaiser Family Foundation.

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 July 12, 2018.

6 Light DW, Lexchin J, Darrow JJ. Institutional Corruption of Pharmaceuticals and the Myth of Safe and Effective Drugs. Journal of Law, Medicine and Ethics, 2013, Vol. 14, No. 3: 590-610.

7 Ibid

8 Murphy, SL, Xu, J, Kochanek KD, Curtin SC, Arias E. Deaths: Final Data for 2015. National Vital Statistics Reports. Volume 66, Number 6, November 27, 2017, Table B. Accessed July 12, 2018.