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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Section I Introduction and Overview
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population 1 Introduction Provision of adequate food, which in turn supplies the needed nutrients and energy, is essential to the health and well-being of all people. In healthy, independently living adults, this process is based on food availability, food intake, and life-style choices, and generally results in an acceptable range of health and nutritional status. The relationship of food, nutrition, and health often changes with aging; with age-related alterations in nutrient requirements; with the acquisition of acute and chronic illnesses; and, in many elderly, with the loss of personal and financial independence. These age-related changes are in part the basis of the significant nutritional risks associated with the older population of Medicare beneficiaries. In the current U.S. health care environment, these personal changes in age, health, and living status are highly influenced by the availability of quality health care and health care funding policy. The number of Medicare beneficiaries is increasing and the cost of medical care is rising. Yet there is a recognition that the currently available Medicare coverage may need to be expanded to include new services previously not covered, including nutrition services. Changes in health care since the inception of Medicare in 1965 have had a significant impact on the delivery of nutrition services to Medicare beneficiaries. The shift from traditionally delivered inpatient care to ambulatory care has reduced the number of hospital beds and increased the severity of illness in the remaining hospitalized patients. Shorter lengths of hospital stays have reduced or eliminated the ability to provide in-
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population depth nutrition counseling, including life-style change counseling, necessary to prevent or treat chronic diseases during the hospital admission. Rapid discharge from the acute care hospital setting has created new dimensions in the continuum of care—transitional or subacute care, home health, and hospice care. In these settings, the provision of nutritional services is not required and monitored with the same rigor as in the acute care setting. The resulting services provided to Medicare beneficiaries often do not adequately address nutrition and lifestyle issues (Posner and Krachenfels, 1987). Yet, with careful planning, these non-acute care settings may be better suited, along with the traditional outpatient office setting, to deliver the nutrition services needed by Medicare beneficiaries. Scientific advances in medical care have increased the need for a multidisciplinary team approach to patient care and a shift from the individual provider model. The need for medical cost containment has led to various approaches to managing care, as well as an increased focus on health promotion, disease prevention, and patient self-management skills for some conditions. The self-management effort has moved to center stage with the development of formal self-management programs in several settings, particularly for diabetes. With increasing emphasis on disease prevention, there has been a proliferation of nutrition-related disease prevention and screening programs targeted at increasing dietary intake of fiber, fruits, and vegetables; reducing the fat content of foods; and increasing specific nutrients such as folate or calcium. In addition, among the fastest-growing areas of the food, pharmaceutical, and related industries are nutrition supplements and herbal products. Older consumers are often among the primary target groups for these companies and are often poorly informed as to the risks, benefits, and costs of including such products in their health care plans. THE COMMITTEE AND ITS CHARGE In accordance with the Institute of Medicine committee process, an expert committee was appointed to undertake the congressionally mandated study looking at nutrition services for Medicare beneficiaries. Financial support for the committee was provided through a contract between the Institute of Medicine (IOM), National Academy of Sciences (NAS) and the Health Care Financing Administration (HCFA), as mandated in the Balanced Budget Act of 1997. The committee was charged with the task of analyzing available information, holding a workshop, and making recommendations regarding technical and policy aspects of the provision of comprehensive nutrition services, including the following:
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population coverage of nutrition services provided by registered dietitians and other health care practitioners for inpatient care of medically necessary parenteral1 and enteral2 nutrition therapy; coverage of nutrition services provided by registered dietitians and other health care practitioners, including registered dietitians, for patients in home health and skilled nursing facility settings; and coverage of nutrition services provided by registered dietitians and other trained health care practitioners in individual counseling and group settings, including both primary and secondary preventive services. In addition, the committee was charged with evaluating, to the extent data were available, the cost and benefit of such services to Medicare beneficiaries and to identify the research issues needed to provide a better understanding of the relationship between the provision of quality nutrition services and quality-of-life outcomes. The Lewin Group, a quantitative analysis consulting firm in the Washington, D.C. area, provided an analysis of the financial impact on the Medicare program given the committee’s recommendations on coverage for nutrition services under contract with the NAS. The committee was composed of 14 individuals with expertise in the areas of geriatric medicine, clinical nutrition and metabolism, epidemiology, clinical dietetics, evidence-based medicine, outpatient counseling, nutrition services management, nutrition support, nursing, health economics, and health policy. Committee members held a variety of professional degrees and represented a geographical cross section of the nation. A complete roster of committee members, including a description of their background and expertise, is included in Appendix I. The committee met over a 5-month period to consider its scope of work; review the relevant scientific evidence; and develop its findings, conclusions, and recommendations. In all, four meetings were held. One meeting included a workshop open to the public. Experts in areas selected by the committee were invited to make presentations and discuss evidence related to particular elements of nutrition services as well as behavioral considerations in the elderly population. During the workshop, a public comment period was held, and interested individuals and organizations were invited to present both oral and written testimony to the committee. Several consultants to the committee participated either through presentations and/or critical review of report sections. The names 1 Delivery of nutrients intravenously rather than through the gastrointestinal tract. 2 Delivery of nutrients through a feeding tube into the gastrointestinal tract.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population of workshop speakers, organizations contacted, and consultants to the committee can be found in Appendix C. Once the committee had completed its initial draft report, a set of reviewers familiar with the issues under discussion and approved by the National Research Council’s Report Review committee individually reviewed and commented on the draft report. These reviewers remained anonymous until the report was finalized. The review process is intended to ensure that the report addresses the committee’s charge, that the conclusions and recommendations are based on scientific evidence, and that the report is presented in an effective and impartial manner. OVERVIEW OF THE REPORT In evaluating nutrition services for the elderly, the committee adopted definitions for common terms which are often referred to in the report. Nutrition services is a broad term which encompasses varied approaches to improving the nutritional health of the elderly from informal nutrition advice and community programs to intensive nutrition counseling and the provision of intravenous feedings. Nutrition services can be divided into two levels. The first tier is basic nutrition services, which includes informal nutrition advice and education. The second tier is more complex and is referred to as nutrition therapy. For the purposes of this report, the term nutrition therapy is defined as the treatment of a disease or condition through the modification of nutrient or whole-food intake. Nutrition therapy encompasses the assessment of an individual’s nutritional status, the evaluation of nutritional needs, interventions or counseling to achieve optimal clinical outcomes, and follow-up care as appropriate. The assessment of nutritional needs takes into consideration the individual’s medical and dietary histories, as well as physical, anthropometric, and laboratory data. Nutrition therapy includes oral, enteral, and parenteral nutrition interventions and takes into consideration the cultural, socioeconomic, and food preferences of the individual. Even though the population of Medicare beneficiaries includes a significant number of individuals younger than 65 years of age with disabilities (about 13 percent) and with end-stage renal disease (about 0.8 percent), this report was designed to focus on the examination of evidence and the role of nutrition services for those age 65 and older. Renal disease was reviewed, but with a more in-depth focus on pre-end-stage disease. Since there were often limited clinical studies on individuals older than 65 years, most of the evidence examined includes study subjects of younger ages.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population The report reviews evidence related to the role of nutrition in several chronic conditions which significantly impact on the morbidity, mortality, and quality of life of the nation’s elderly. While there are likely other conditions for which evidence regarding the role of nutrition exists, it was beyond the scope of this report to review evidence related to all medical conditions. The conditions which the committee chose to review in depth—dyslipidemia, heart failure, hypertension, diabetes mellitus, renal failure, and osteoporosis—do not imply that other conditions were of less importance. The conditions chosen were those that the committee felt had not only a significant impact on morbidity and mortality in this population, but also had sufficient data available to evaluate. In the elderly, obesity is common and most often occurs with other important clinical conditions for which there is significant scientific literature, such as hypertension, heart failure, diabetes, and hyperlipidemia. For reasons discussed in chapter 2, the committee chose to include and review scientific evidence of nutrition services for obesity only within each of the associated clinical conditions and chapters where applicable. This report is organized into four sections: Section I (chapters 1–3) sets the stage for the report—giving an overview of the Medicare program, nutritional concerns in older persons, as well as the methods committee members used to guide them through their deliberations. Section II (chapters 4–8) addresses the conditions reviewed in this report which can affect elderly individuals in health care settings across the continuum of care: ambulatory (outpatient care), acute care hospitals (inpatient care), sub-acute and long-term care facilities, and home care. For this reason, the efficacy of the role of nutrition in diseases or conditions is independent of particular settings of care. Each of the condition-specific chapters addresses the strength of the evidence for the efficacy of the role of nutrition, makes recommendations regarding the provision of services to Medicare beneficiaries, and addresses research gaps in areas where evidence is needed. Section III (chapters 9–12) addresses the continuum of care: short-stay acute care facilities (hospitals), ambulatory care (outpatient services), home care, and skilled nursing and long-term care facilities. It also addresses the delivery of nutrition support (enteral and parenteral feedings) which may be needed and provided in any of the above settings. Section IV (chapters 13–15) presents the committee’s findings regarding providers of nutrition services, cost estimates of providing services found to be efficacious to Medicare beneficiaries, and a summary of the committee’s conclusions and recommendations.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population OVERVIEW OF THE MEDICARE PROGRAM3 Congress created the Medicare program in 1965 to provide health insurance for Americans age 65 or over. It later extended coverage to some individuals with disabilities or permanent kidney failure. From the outset, the program has focused on hospital, physician, and certain other services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” (section 1862 of the Social Security Act). With certain exceptions, Congress explicitly excluded coverage for preventive services, outpatient prescription drugs, dental care, and long-term nursing home care and other supportive services for people with chronic disabling conditions. Most sessions of Congress see proposals to expand Medicare coverage for one or more of the services that are currently excluded. For example, while this report was being drafted, Congress was debating the addition of outpatient drug benefits, which even under the most limited proposals would add substantially to the program’s costs. With growth in Medicare spending and health care costs having far exceeded 1960s’ estimates, the increased cost of additional services has generally discouraged coverage expansions. Moreover, Congress has set budget rules for itself requiring that decisions to increase most types of federal spending must be accompanied by explicit decisions to reduce spending elsewhere or to raise taxes. These rules underscore the reality that expanding Medicare coverage involves making trade-offs to face the resource constraints. In the Balanced Budget Act of 1997 (Public Law 105-33), Congress called for the Department of Health and Human Services to arrange for the NAS to analyze “the short- and long-term benefits, and costs to Medicare” of extending coverage for certain preventive and other services. These services were screening for skin cancer; medically necessary dental services; elimination of time restrictions on coverage for immunosuppressive drugs after transplants; nutrition therapy; and routine patient care for beneficiaries enrolled in approved clinical trials. This request from Congress reflects two significant developments since Medicare’s beginnings: an accelerating pace of technological innovation and—partly as a consequence—a greater than anticipated escalation of program expenditures and overall health care costs. Scientific and technological advances have clearly led to a multitude of new medical procedures, drugs, devices, and other services that prolong life, protect physical and mental functioning, prevent disease, and otherwise improve 3 Excerpted and adapted from the companion report Extending Medicare Coverage for Preventive and Other Services (IOM, 2000).
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population people’s health and well-being. Of course, not all innovations perform as promised. Moreover, most new—and established—technologies have risks that must be weighed against expected benefits. Cost constraints also require that trade-offs be made. Historical Background When Congress—following years of debate—created Medicare as Title XVIII of the Social Security Act (SSA), it was responding to the growing availability of effective medical services and the difficulty faced by older people in either paying for these services directly or obtaining private health insurance.4 At the same time, Congress also created the federal–state Medicaid program (Title XIX of the SSA), which provided health insurance for certain categories of low-income individuals (especially low-income mothers and children and low-income aged, blind, or disabled people). Reflecting the needs of these lower-income beneficiaries, Medicaid covers a generally broader array of services (e.g., well-baby visits, extended nursing home care). It also provides states some flexibility in deciding what to cover (e.g., certain dental services, outpatient prescription drugs). Certain low-income people, called “dual eligibles,” qualify for full or partial Medicaid benefits as well as regular Medicare coverage. Their Medicaid benefits cover many of the Medicare program’s cost-sharing requirements and “fill-in” some of the gaps in Medicare benefits. In 1972, Congress expanded Medicare to cover certain disabled persons and created a unique entitlement to coverage for people who suffer from end-stage renal disease (ESRD). Continuing a division that had emerged earlier in private health insurance, the Medicare program as initially created had two parts: hospitalization insurance, also known as HI or Part A, and supplementary medical insurance for physician and certain other services, also known as SMI or Part B.5 Part A, which is financed by payroll taxes (1.45 percent paid by employers and employees), covers inpatient hospital care subject to an annual deductible set at $768 in 1999 and a per-day copayment after 60 days. It also covers (subject to various time limitations, cost-sharing 4 This discussion draws on Ball, 1995; Feingold, 1966; Harris, 1969; Marmor, 1973; Somers and Somers, 1961, 1967, 1977a, b; Starr, 1982; Stevens, 1989. 5 In 1997, as part of the Balanced Budget Act, Congress created Part C (also known as Medicare+Choice), which restructured and expanded options for Medicare beneficiaries to enroll in approved health maintenance organizations and other private health insurance plans. These plans, which are paid a fixed monthly amount per enrolled beneficiary, must provide Medicare-covered services but may also offer additional benefits.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population requirements, and other restrictions) services provided by other institutional providers including skilled nursing facilities and hospices. One rationale for covering these kinds of services has been that such coverage may encourage the use of alternatives to more expensive hospital care. Part B covers physician and certain other professional services provided in the hospital, office, and selected other settings. It also covers a number of additional services such as outpatient hospital care, outpatient dialysis services, clinical laboratory tests, durable medical equipment, ambulance services and, since 1997, most home health care services. For part B coverage, beneficiaries pay a monthly premium (set to cover 25 percent of Part B expenditures or $45.50 per beneficiary in 1999) and coinsurance of 20 percent for most services. Part A coverage is virtually automatic for those eligible, but enrollment in Part B is voluntary, although nearly all of those eligible do enroll. As noted above, the legislation creating Medicare excluded coverage for services not deemed “reasonable and necessary” for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Preventive services, dental care (except in very limited situations related to serious medical problems), and outpatient prescription drugs were among the services categorically excluded in 1965. One rationale for excluding preventive services from Medicare was that they did not fit the traditional insurance model of providing coverage for expenses that are unpredictable (and thus cannot be budgeted) and substantial (and thus are a serious financial burden for individuals and families). When Medicare was created, hospitalization and other major expenses related to care for acute illnesses fit the model; expenses for most preventive services then available, outpatient prescription drugs, and dental care did not. In addition, insurance principles also discouraged coverage for “broad and ill-defined” services such as routine physicals and health education or counseling (Breslow and Somers, 1977; OTA, 1990). Since 1965, Congress has authorized a few exceptions to the coverage exclusions just described. After rejecting 350 bills to make one or more exceptions to Medicare’s exclusion of preventive services, Congress approved its first exception—for pneumococcal pneumonia vaccine—in 1980 (Schauffler, 1993), and more exceptions have followed. Congress has waived the application of the Part B deductible and coinsurance provisions for some covered preventive services. Because of gaps in Medicare coverage, about 80 percent of beneficiaries purchase or otherwise obtain some form of supplemental coverage to help pay for certain excluded services, deductibles, and copayments or coinsurance (HCFA, 1998a). This coverage may be provided through an
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population employer-sponsored program, an individually purchased “Medigap” policy, or a state Medicaid program. Medicare beneficiaries covered by health maintenance organizations (HMO) may be eligible for additional preventive and other services, sometimes by paying an additional premium, but HMOs vary greatly in the extent to which they offer benefits not required by Medicare (Kaiser Family Foundation, 1998). Enrollment and Expenditure Trends Since the program was implemented, the number of Medicare beneficiaries has roughly doubled, from 19.1 million when the program began in 1966 to approximately 38.4 million for 1997 (about 4.8 million of whom qualify for Medicare due to disability and about 0.3 million due to ESRD) (HCFA, 1999a). The growth in Medicare enrollment will accelerate as the baby boom generation begins to reach age 65 (and becomes eligible for coverage) in 2011. By 2015, the population age 65 years and over is projected to reach 56.3 million. Unless age or other eligibility requirements change, virtually all will be covered by Medicare. Those qualifying because of disability or ESRD are expected to constitute a somewhat larger fraction of the total beneficiary population by 2015 (about 16 percent compared to 13 percent in 1997). Initial forecasts of program spending proved to be gross underestimates of actual spending. While the number of beneficiaries was doubling, Medicare net outlays grew from $2.7 billion in 1967 (the program’s first full year) to $174.2 billion in 1996 (U.S. House of Representatives, 1997, 1998). (In constant 1995 dollars, 1967 expenditures would amount to about $10 billion.) Current debates about Medicare’s future revolve primarily around predictions that Part A of the program will become insolvent (spending will exceed revenues) early in the twenty-first century. Projections of long-term Medicare program costs—and health care costs more generally—have many uncertainties (White, 1999), but the predictions of future funding shortfalls are being taken seriously. Nonetheless, concerns about federal spending and program solvency have prompted discussions of major and controversial changes such as raising the age of eligibility, instituting some kind of means testing, directing more beneficiaries into capitated managed care plans, and establishing a formula for the government’s contribution to program costs that would shift more of the risk for continued health care cost escalation to beneficiaries. A major component of the Balanced Budget Act of 1997 was a set of measures to slow the growth in program spending and at least delay the date at which Medicare spending is projected to exceed revenues (Kahn and Kuttner, 1999).
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population quests for assessments of clinical preventive measures, immunosuppressive drugs, and other services. The OTA analyses considered scientific and clinical issues but were also explicitly intended to provide guidance to policymakers by examining the cost-effectiveness of clinical interventions, possible costs to Medicare of extending coverage, and other policy issues. For categories of covered services, Congress has authorized the HCFA to establish procedures for making more specific coverage decisions about individual services within the broad categories established legislatively. It could also authorize HCFA (which is part of the Department of Health and Human Services) or a quasi-public body either to make coverage exceptions for services that now fall in the categories of generally excluded services. For example, the early 1990s discussion of health care reform saw various proposals for delegating decisions about preventive services (OTA, 1993). Health Care Financing Administration Within the broad coverage categories established by Congress, more specific determinations about what services are or are not covered are the responsibility of the Health Care Financing Administration (Bagley and McVearry, 1998). HCFA also provides detailed guidance to Medicare contractors regarding the application of its coverage rules and the development of local contractor medical policies for situations not dealt with by such rules. Altogether, HCFA has issued about 700 national coverage policy decisions (John Whyte, Health Care Financing Administration, Baltimore, Maryland, personal communication, July 1999). These decisions typically involve either new services and technologies or new indications (clinical circumstances) for the use of technologies that had previously been covered for a limited set of indications. Some determinations restrict coverage of an already covered service—usually because new evidence suggests the service is unsafe or ineffective. The coverage determination process may involve reviews of the scientific evidence, consultations with clinical experts, and comparisons with similar technologies. Some technology assessments are conducted by HCFA staff, whereas others are referred to different governmental or private organizations including the federal Agency for Healthcare Research and Quality (AHRQ) and its Evidence-Based Practice Centers (EPCs). Created by Congress in 1989, AHRQ supports an array of activities intended to increase and evaluate the evidence base for health care services. The EPCs—many of which are consortia or partnerships of universities and other institutions—produce evidence reports and technol-
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population ogy assessments on topics as requested. If nongovernmental parties request a coverage determination from HCFA, they are expected to provide supporting documentation including reviews and analyses of the scientific evidence, unless they lack the resources to do so. In making coverage determinations, HCFA must follow federal rule-making procedures and requirements. After criticism that agency procedures violated federal open government rules, HCFA created a new Medicare Coverage Advisory Committee, for which administrative procedures are being developed and reviewed.7 A typical candidate for the committee review would be a new technology or new use of an established technology relevant to an existing coverage category. Various gene therapies are examples of the former and innovative uses of lasers are examples of the latter. HCFA has interpreted the congressional requirement that services be covered only if “reasonable and necessary” for the diagnosis or treatment of an illness or injury to mean that they must be (1) safe and effective, (2) provided in an appropriate setting, and (3) not experimental or investigational (HCFA, 1989). The criteria and processes for determining what services are medically necessary have been the subject of much debate and dissatisfaction (e.g., see Anderson et al., 1998; Bergthold, 1995; Cunningham, 1999; IOM, 1992; NHPF, 1998, 1999). In January 1989 and as recently as 1996, HCFA proposed to consider the cost-effectiveness of technologies as part of the coverage review process (Health Systems Review, 1997). The proposal provoked considerable controversy and was never adopted. HCFA should shortly be issuing a new Federal Register notice proposing national coverage criteria. Because individual coverage determinations by HCFA are not directly governed by the “budget neutrality” rules of Congress, new services that fit within established coverage categories face different hurdles to coverage approval than do services that require congressional action. Administrative Contractors In practice, many coverage determinations, perhaps 90 percent (HIMA, 1999), are made not by HCFA but by the 60-plus private contractors that the agency uses to administer payment of Medicare claims on a state, substate, or multistate basis. On the Part A side, these organizations 7 This committee will operate under the Federal Advisory Committee Act (HCFA, 1998b). HCFA has also published a notice explaining the new process of making national coverage decisions (HCFA, 1999c). A notice on proposed coverage criteria is expected by the end of 1999.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population are called “intermediaries.” For Part B, which generates nearly all of these coverage questions, they are known as “carriers.” HMOs and other private health plans approved by Medicare to serve beneficiaries must follow intermediary and carrier policies, but they also must make their own coverage determinations in the absence of such policies. Frequently, it is these private carriers that first encounter questions about new medical services or services for which coverage is sought beyond the uses originally recognized. Their determinations are codified in the form of local medical review policies. Local medical policies may also specify more precisely the appropriate indications for established technologies for which excessive use is suspected. This is consistent with HCFA’s description of medical review policy as a “program integrity” tool intended to protect the program from fraud and abuse (HCFA, 1999b). Carriers make decisions about payment after services have been provided. HCFA uses another group of contractors, Peer Review Organizations (PROs) to conduct prior reviews of certain surgical procedures and engage in other activities intended to improve the quality of care provided to Medicare beneficiaries. Contractors administering provider claims for payment must coordinate with the appropriate PROs to assure that payments are made consistent with the PROs’ decisions (HCFA, 1999b). HCFA’s new procedures for national coverage decision making make clear that local medical policy decisions cannot conflict with a national decision by HCFA. Other HCFA policies direct carriers to base policies on the best evidence available, cite the basis and references for local medical policies, submit the policies to their Carrier Advisory Committees, publish them in their provider bulletins, and consider comments submitted in response (HCFA, 1999b). Carriers may conduct their own assessments of new or established services and technologies, or they may rely on others, for example, ECRI (originally the Emergency Care Research Institute) or the Technical Evaluation Center of the Blue Cross and Blue Shield Association (both of which are designated EPCs). Carrier coverage policies are generally prompted by the need to make determinations about coverage of a service provided to a specific individual rather than by, for example, a request for a policy or by the anticipation of claims related to an emerging technology. When the judgments are negative, such case-by-case negative decisions may readily evoke images of big, impersonal bureaucracies refusing to pay for innovative treatments that provide the last hope for desperately ill individuals. Controversies about such negative coverage decisions—and conflicting decisions from different carriers—may then prompt HCFA on its initiative or at the request of others to develop a uniform national policy. In addition to revising procedures for national coverage decision making and clarifying
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population the role of local organizations in the coverage process, HCFA has a contractor examining variation in local medical policies. MEDICARE COVERAGE OF NUTRITION SERVICES A summary of current Medicare coverage of nutrition services along the continuum of care is presented in Table 1.1. The information is somewhat simplified and does not reflect all possible instances but serves as the general assumptions of current coverage by the committee. TABLE 1.1 Medicare Coverage of Nutrition Services Service General Coverage Nutrition Services Coverage MEDICARE PART A Hospital inpatient care Medicare reimburses hospitals a bundled payment, based on diagnosis, for all services provided by the facility, including bed and board, nursing and related services, diagnostic and therapeutic services, drugs, and supplies. The hospital conditions of participation require a hospital to have a full-time employee who serves as director of the food and dietary service; is responsible for the daily management of the dietary services; and is qualified by experience and training. There must be a qualified dietitian, full-time, part-time, or on a consultant basis. There must be administrative and technical personnel competent in their respective duties. Menus must meet the needs of the patients. Therapeutic diets must be prescribed by the practitioner responsible for the care of patients. Nutritional needs must be met in accordance with orders of the practitioner responsible for the care of patients. The facility must ensure that residents receive proper treatment and care for, among other special
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Service General Coverage Nutrition Services Coverage Hospital inpatient care (continued) services, parenteral and enteral fluids. Nutrition services are included as part of the hospital’s bundled payment and are not reimbursed as a separate charge. Skilled nursing facility (SNF) care Medicare pays SNFs a per diem payment that covers bed and board, nursing and related services, therapeutic services, drugs, and supplies. Conditions of participation include the following: “The facility must assure that a resident maintains acceptable parameters of nutritional status (unless the resident’s clinical condition demonstrates that this is not possible) and receives a therapeutic diet when there is a nutritional problem.” In addition, section 483.35 is as follows: “The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.” The subparagraphs of this section address (a) staffing (indicates a qualified dietitian must be employed or contracted with on a consultant basis); (b) sufficient dietary staff; (c) menus and nutritional adequacy; (d) food; (e) therapeutic diets; (f) frequency of meals; (g) assistive devices; and (h) sanitary conditions. Nutrition services are included as part of the SNFs per diem payment and are not reimbursed as a separate charge.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Service General Coverage Nutrition Services Coverage Home health care Medicare Part A covers up to 100 visits of home health care following a 3-day hospital stay if rendered within 14 days of discharge. Home health agencies are paid on a cost basis, up to certain limits. Beginning in 2001, home health services will be paid under a prospective payment system. While each covered home health service will be bundled into the rate, each covered service will appear in the consolidated billing provided to patients. Although very limited, administrative costs associated with the provision of nutrition services are included in the benefit. While home health agencies are required to have specialized nutrition expertise in order to be Medicare certified, nutrition services are not reimbursed as a separate charge. Hospice care The Medicare hospice benefit is limited to patients with a life expectancy of 6 months or less. Hospices are paid per diem rates for provision of pain relief, symptom management, and support services. Part of the core services that must be provided by Medicare certified hospices is dietary counseling. Rural hospices may obtain a waiver, which will allow hospices to contract out for counseling. Dietary counseling is included in the per diem rate and is not reimbursed as a separate charge. MEDICARE PART B Health care provider visits Medicare pays physicians and certain other health care professionals (e.g., dentists, chiropractors, optometrists, podiatrists, advanced practice nurses, physician assistants, psychologists, social workers, physical and occupational therapists) according to the Medicare fee schedule. Some nonphysician practitioners Nutrition services provided by health professionals recognized by Medicare as “certified providers” may receive reimbursement if the service is deemed reasonable and medically necessary. For example, a physician may counsel a patient regarding a diet and bill for the time spent with the patient under an office visit
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Service General Coverage Nutrition Services Coverage Health care provider visits (continued) may be reimbursed only for certain procedures (e.g., chiropractors may be reimbursed by Medicare only for spinal manipulation). Some nonphysician practitioners may receive less than the full Medicare fee schedule amount (e.g., advanced practice nurses and physician assistants receive 85% of the payment that would be made to a physician for the same service). “evaluation and management” code. Nutrition services may also be reimbursed by Medicare when nutrition services are provided “incident to” a physician’s service if deemed reasonable and medically necessary. All requirements of “incident to” must be met. The physician must perform the initial service and subsequent services with a frequency that reflects the active participation of or management by the physician during the course of treatment. “Incident-to” services must be provided by an employee of a physician or physician group practice and must be directly supervised by the physician billing for the services. Registered dietitians in independent practice are not authorized by Medicare to receive reimbursement for providing nutrition services. Hospital outpatient department care Medicare has in the past reimbursed hospital outpatient departments on a cost basis. Effective in 2000, hospital outpatient departments will be paid on a prospective payment basis and receive bundled payments based on the classification of the procedure performed. The payments will cover all facility costs, diagnostic Nutrition services provided as part of a patient educational program, such as a diabetes education or cardiac rehabilitation program may be covered if they are furnished “incident to” a physician’s service and if deemed reasonable and medically necessary for the individual patient. Nutrition counseling by a
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Service General Coverage Nutrition Services Coverage Hospital outpatient department care (continued) tests, drugs, supplies, etc., necessary for the procedure. qualified dietitian, which does not meet the “incident to” medically necessary requirements for the individual patient, is not covered. Payment is made to the facility for the whole program. Diabetes self-management training A new benefit effective in 1998. Regulations for reimbursement and qualifications of certified programs are currently under development. The nutrition component of the benefit is reimbursed as part of the total payment. Dietitians are required to be involved with a certified program; however, they cannot sponsor a program or receive Medicare reimbursement because they are not recognized independent providers under the Medicare program. Routine preventive services Medicare covers only certain preventive services: flu, hepatitis B, and pneumonia vaccines; mammography; pelvic exams and Pap smears; colorectal cancer screening; bone mass measurements; and prostate screening. Payment is made for professional services or for laboratory tests according to the applicable fee schedule. In general, nutrition services provided for primary prevention are not covered. Home health care Home health services reimbursed under Part B include those not related to an inpatient stay or visits in excess of 100 following an inpatient stay. Reimbursement methods are the same as for Part A (see above). See home health services under Part A above.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Service General Coverage Nutrition Services Coverage Prosthetic device benefit Medicare covers reasonable and necessary prosthetic devices and reimburses based on a fee schedule. Parenteral and enteral nutrition provided on an outpatient basis is covered to a limited degree under the prosthetic device benefit. Outpatient renal dialysis facilities Medicare pays a composite rate for dialysis services furnished in outpatient renal dialysis facilities. Nutritional services are included under the composite rate. Under the conditions for coverage, each facility must provide dietetic services to meet the needs of patients; employ or have a contractual relationship with a qualified dietitian who, in consultation with the attending physician, assesses the nutritional and dietetic needs of each patient, recommends therapeutic diets, counsels patients and their families on prescribed diets, monitors adherence and response to prescribed diets, and records findings in the patient’s medical record. The full range of dialysis services, including personnel services for dietitians, is covered under the composite rate. MEDICARE+CHOICE (M+C) Private health plans M+C plans are paid global capitated amounts by Medicare and must provide all Medicarecovered benefits to enrollees. M+C plans make their own arrangements for payment of providers and may provide nutrition services over and above Medicare requirements as an extra benefit to enrollees.
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