On April 5, 2013, the Alliance for Natural Health USA (ANH) and Certified Board for Nutrition Specialists (CBNS) each filed comments opposing a Medicare reform regulation proposed by the Centers for Medicare & Medicaid Services (CMS). CMS proposed regulatory revisions to promote program efficiency, transparency, and burden reduction. See 78 Fed. Reg. 9216-01 (Feb. 2013). A copy of the Proposal Rule is available here.
As part of those reforms, CMS intends to revise hospital requirements in 42 CFR § 482.28(b) “currently requir[ing] that a therapeutic diet must be prescribed only by the practitioner or practitioners responsible for the care of the patient.” CMS now proposes to extend hospital ordering privileges to Registered Dietitians (RDs). It claims that “RDs are the professionals who are best qualified to assess a patient’s nutritional status and to design and implement a nutritional treatment plan in consultation with the patient’s interdisciplinary care team.”
Both CBNS and ANH challenge CMS’s proposed revisions to Section 482.28(b). They recommend revising the rule to encompass “qualified nutritionists” in addition to registered dietitians. CBNS and ANH agree that expanding flexibility in hospital settings to accommodate nutrition professionals is a laudable goal. By permitting non-physician privileges in the realm of nutritional care, hospitals can promote cost-effective and specialized care for more patients. CMS explained in the Proposed Rule that use of nutrition professionals increases the hospital’s ability to “promote timely, cost-effective, and evidence-based nutrition services” and “saves valuable time in the care and treatment of patients, time that is now often wasted as RDs must seek out physicians, APRNs, and PAs to write or co-sign dietary orders.” See 78 Fed. Reg. at 9223.
Unfortunately, CMS’s Proposed Rule stopped with Registered Dietitians and excluded a broader universe of well-qualified professionals. That exclusion renders the Proposed Rule ineffective and discriminatory. CMS and ANH explain that entry-level RDs may lack the requisite education and experience to fulfill CMS’s regulatory goal. The RD credential is bestowed by a private trade association. That credential, by itself, is not proof of competence to order therapeutic nutritional protocols. To properly manage the nutritional care of a patient in clinical settings, a professional should have advanced training and proficiency attained through graduate-level coursework. The RD credential requires only achievement of a Bachelor’s degree, sometimes with little practical coursework. The Academy of Nutrition and Dietetics (the governing body for Registered Dietitians) has acknowledged that it should increase educational prerequisites.
Moreover, while CMS’s proposal benefits certain under-qualified professionals, it also excludes those with superior credentials. For instance, Certified Nutrition Specialists (CNS) must have a Masters or PhD in a field of clinical healthcare from a regionally accredited college or university. They must complete substantial coursework in Biochemistry, life sciences, and Clinical Nutrition. They must meet a minimum of 1,000 hours of documented, supervised clinical work in the relevant field, and pass a rigorous credentialing examination wherein 95% of the material tested relates to clinical issues. A CNS is more qualified than an entry-level RD in the field of clinical nutrition. Accordingly, ANH and CBNS explain that CMS acts arbitrarily and capriciously by excluding all professionals without RD credentials. Also, by arbitrarily favoring one private credential over all others, CMS likely violates the Equal Protection Clause of the U.S. Constitution.
ANH and CBNS hope that by raising these significant issues CMS will consider revising its Proposed Rule. Otherwise, CMS’s proposed revisions unreasonably restrict competition within the field of clinical nutrition without any reasoned basis. Medical staff should have flexibility to determine the best qualified individuals under the hospital’s bylaws and policies. Staff should have leeway to appoint qualified candidates, whether RDs with graduate-level experience or Certified Nutrition Specialists. By expanding the regulatory language, ANH and CBNS encourage options that will ultimately improve patient care. For more information, please read the comments here (ANH Comments | CBNS Comments).