On February 7, 2013, the Center for Medicare and Medicaid Services (CMS) published a proposed rule in the Federal Register, 78 Fed. Reg. 9216 (Feb. 7, 2013). Buried in that rule is a proposed revision to Section 482.28 of 42 CFR Part 482 concerning Food and Dietetic Services. At present, that rule requires a therapeutic diet to be prescribed only by the practitioners treating the patient (ordinarily M.D.s, D.O.s, APRNs, or PAs). Under the proposed revision, registered dietitians will be exclusively permitted addition to that list, such that they will be able to prescribe medical nutrition therapy to patients independent of attending physicians.
The proposed rule includes braggadocio in favor of the change, stating: “We believe 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.” Indeed, CMS goes on: “the RD must be viewed as an integral member of the hospital interdisciplinary care team, one who, as the team’s clinical nutrition expert, is responsible for a patient’s nutritional diagnosis and treatment in light of the patient’s medical diagnosis.”
Rather than open the door to competent, graduate level nutrition experts in prescribing therapeutic diets for those in the hospital, this rule proposes an anti-competitive niche for dietitians to assume that role. At least three major problems arise from this proposed revision.
First, the RD credential is bestowed on individuals who are not “clinical nutrition experts” if by that term we mean individuals qualified by education, training, and experience to diagnose the peculiar nutritional needs of individuals suffering from ailments, being treated with drugs, or recovering from surgery. One need only have a bachelor of science degree and certain experience to qualify for the RD exam and the exam itself does not include questions that would provide a detailed assessment of the test takers understanding of biochemistry, pharmacology, or nutrition science. Consequently, the CMS proposed rule invites individuals who may not be qualified to render clinical nutrition opinions the power to so do. For sure, some RDs also possess Ph.D.s or other graduate level degrees in relevant areas of science, but the fact that they have an RD is not in and of itself sufficient to justify a role in clinical nutrition. As most of us know, RDs are most often involved in food service functions within hospitals and are rarely permitted to make basic diagnosis decisions nor should they given their paucity of scientific training.
Second, there are many individuals who possess graduate level degrees in clinical nutrition, nutrition science, and related fields that are better able to evaluate the often complex biochemistry associated with clinical nutrition in the hospital setting. Those individuals include the people who have been certified as nutrition specialists by the Certification Board for Nutrition Specialists. I am a member of the board of directors of that organization. To be eligible for the CNS credential, a person must not only possess a graduate level degree in clinical nutrition, nutrition science, or a related biomedical field, he or she must also have extensive experience in the appropriate settings, and pass a rigorous exam that is a detailed assessment of acumen in areas of biochemistry, biology, pharmacology, and nutrition science directly germane to the clinical nutrition profession.
Third, if this CMS rule is adopted as proposed, it will have the perverse effect of locking out of medical nutrition therapy a large universe of people who do not possess the RD credential but who are exceedingly well qualified to opine on such matters. That will be to the detriment, perhaps the grave detriment, of patients. Rather than improve the quality and degree of care afforded, the proposed rule locks in substandard care and reinforces an RD guild inside the nation’s hospitals.
Comments in response to this CMS proposed rule are due on or before April 8, 2013. Those interested in opposing it should contact me at firstname.lastname@example.org.