Comments to HRSA re Loan Repayment for RDNs in NHSC

June 6, 2016

Beth Dillon
Director, Division of Regional Operations
Bureau of Health Workforce
1961 Stout Street
Denver, Colorado 80294

Re: Recruitment of Sites for Assignment of Corps Personnel Obligated Under the National Health Service Corps (NHSC) Scholarship Program

Dear Ms. Dillon,
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Health Services & Resources Administration (HRSA) regarding the May 5, 2016 general notice "Recruitment of Sites for Assignment of Corps Personnel Obligated Under the National Health Service Corps (NHSC) Scholarship Program." Representing over 90,000 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. RDNs serving in the U.S. Public Health Service (USPHS) Commissioned Corps "play key roles as they work to protect, promote, and advance the health and safety of the Nation."2

The Academy strongly encourages HRSA to recommend to Congress (and specifically the Senate Health, Education, Labor, and Pensions Committee) that it amend the Public Health Service Act (the "Act") to include RDNs as qualified providers eligible3 for the NHSC Loan Repayment Program (LRP) managed by the Bureau of Clinician Recruitment and Service (BCRS) at HRSA. This amendment would enable HRSA to:

  1. More effectively accomplish the intention of the general notice to "provide a continuum of services, including comprehensive primary health care and appropriate referrals;"
  2. Align the NHSC with various other federal health services; and
  3. Best utilize and incentivize RDNs who already work at Federally Qualified Health Centers and are statutorily eligible to provide telehealth services in designated HPSAs.

A. Statutory Changes Needed

Loan repayments are for primary care, dental, behavioral, and mental health clinicians who agree to at least two years of service in an NHSC-approved site in a Health Professional Shortage Area (HPSA). The statutory amendments necessary to accomplish this clinically and cost-effective strategy for providing preventive health to underserved populations include:

  • 42 USC § 254d(a)(3)(D)
    • Add "dietetics or nutrition," after "dentistry"
  • 42 USC § 254d(b)(1)
    • Add "dietetics or nutrition," after "dentistry"
  • 42 USC § 254d(b)(2)
    • Strike "and" in front of "physician assistants"
    • Add ", and registered dietitians" after "physician assistants"
  • 42 USC § 254f(e)
    • Add "dietetics," after "dentistry" NOTE: not "dietetics or nutrition" here, as some states license low level nutritionists who would not be "health professionals" under federal law
  • 42 USC § 254f-1(a)(3)
    • Add "dietetics," after "dental,"
    • Add "registered dietitians," after "dentists,"
  • 42 USC § 254l(a)(1)
    • Strike "and" in front of "physician assistants"
    • Add ", and registered dietitians" after "physician assistants"
  • 42 USC § 254l(b)(1)(A)
    • Add "dietetics or nutrition," after "dentistry"
  • 42 USC § 254l(b)(1)(B)
    • Add "dietetics or nutrition," after "dentistry"
  • 42 USC § 254m(b)(2)(C)(ii)
    • Add "dietetics or nutrition," after "dentistry"
  • 42 USC § 254m(b)(2)(C)(iii)
    • Add "dietetics or nutrition," after "dentistry"

B. Alignment of NHSC with Other Loan Repayment Programs

The Public Health Service Act (the "Act") has previously been amended to add additional qualified providers to the category of primary care and mental and behavioral health providers. This proposal remedies the oversight in not originally including RDNs in the list of eligible providers for the NHSC LRP and thus brings greater consistency to the Act where RDNs have elsewhere been included as eligible providers for LRPs, aligning the NHSC LRP with both the Indian Health Service's (IHS) list of eligible health professions4 for its LRP5 and BCRS's other LRP programs, including its Faculty Loan Repayment Program.6

C. RDN Background and Training

Dietitian qualifications are a 4 year degree in dietetics or nutrition with a 9 - 12 month internship or completion of a coordinated undergraduate program that combines classroom and clinical experience. RDNs are recognized as independently reimbursable providers in Medicare with qualifications defined in the Social Security Act §1861(vv)(2) and are already officers in the Commissioned Corps of the U.S. Public Health Service throughout the country and in various agencies, where they are demonstrating effectiveness in disease prevention and treatment and community health promotion that positively impact disease rates, health care costs, and patients' lives.7 The effectiveness of RDNs in the IHS's Diabetes Prevention and Healthy Heart Initiatives could bring that effectiveness in treating diabetes, cardiovascular disease, chronic kidney disease, and obesity to populations in need living in HPSAs.8,9 RDNs are also already reimbursable providers in these underserved areas.10

D. Conclusion

The Academy appreciates the opportunity to comment on the general notice and make the above recommendations that will enhance access to care, lower costs, and improve health, and could provide a significant benefit in improving preventive care and treatment within the HPSAs. We would be grateful for the opportunity to discuss these recommendations in greater detail in the near future with you or with another HRSA official you may recommend. 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 Quote from Captain Edith Clark, Chief Dietitian Officer. Commissioned Corps of the U.S. Public Health Service website. Accessed June 3, 2016.

3 National Health Services Corps Loan Repayment Program website. Accessed June 3, 2016.

4 Eligible Professionals. Indian Health Service website. Accessed June 3, 2016.

5 Loan Repayment Program. Indian Health Service website. Accessed June 3, 2016.

6 Faculty Loan Repayment Program. HRSA website. Accessed June 3, 2016.

7 U.S. Public Health Service Commissioned Corps, Dietitian Officers, Best Kept Secrets. Accessed June 3, 2016.

8 Morbidity and Mortality Weekly Report. CDC website. Accessed June 3, 2016.

9 Delahanty LM, Nathan DM. Implications of the diabetes prevention program and Look AHEAD clinical trials for lifestyle interventions. J Am Diet Assoc. 2008;108(4 Suppl 1):S66-72.

10 Telehealth Services. CMS website. Accessed June 3, 2016.