Starved for Coverage: Closing the Coverage Gap for Medical Nutrition Services

                                                                 Anthony Zhong, MA 



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The human costs of poor nutrition are staggering in the United States. Unhealthy diets are responsible for over 350,000 deaths each year. Annual healthcare spending attributable to dietary risks is estimated to be $143.6 billion. Medical Nutrition Therapy (MNT) involves behavioral counselling and nutrition education, often under the guidance of a registered dietitian. It has been shown to be effective in the prevention and management of many diet-related diseases, including obesity, high cholesterol, diabetes, kidney diseases, and cardiovascular diseases.

Yet, despite its benefits, MNT is treated as an ancillary service rather than an essential one. Currently, Medicare only covers MNT for patients with diabetes or kidney disease. Coverage for other conditions is limited and varies by plan. Additionally, there are significant disparities in access to MNT based on sociodemographic factors.

The lack of coverage for MNT is a missed opportunity for the prevention of chronic diseases. For example, one systematic review of 13 randomized controlled trials found that MNT was effective in improving glycemic outcomes, anthropometrics, blood pressure, and lipid levels in patients with prediabetes. Waiting for patients to progress to diabetes before offering nutrition services compromises their health. It also represents a missed opportunity for cost savings, as chronic disease progression and multimorbidity are associated with higher healthcare costs and increased resource utilization.

​More than that, coverage gaps leave vulnerable patients without care. The American Cancer Society makes it clear that nutrition is essential to cancer care; it not only helps patients tolerate treatments such as chemotherapy and radiation, but it also promotes recovery and long-term health. Poorly nourished patients experience longer hospital stays, as well as higher rates of complications, readmissions, and death. Still, the Affordable Care Act does not require coverage for oncology nutrition services. Current Centers for Medicare & Medicaid Services (CMS) programs do not cover these services, and most cancer centers, consequently, do not bill for them. The result is that health centers are incentivized to limit access to uncompensated nutrition services, to restrict staffing, and to cut programs when financial difficulties arise.

Without dedicated resources and staffing, the burden of nutrition counselling often falls on primary care clinicians. However, this approach is ineffective and unsustainable, as the average primary care visit lasts 18 minutes – not nearly enough time for comprehensive nutrition education or counseling. When there are competing priorities and lengthy problem lists, it should come as no surprise that nutrition falls by the wayside. Indeed, in a national survey of 3,000 individuals, fewer than half agreed that their primary care providers gave clear advice about food and nutrition. Just 33.8% of patients with household incomes below $25,000 were asked about their diet, and only 15.6% of patients on Medicaid were asked if they had enough food to eat.

Ultimately, the lack of coverage requirements for nutrition services leads to unsustainable payment models without adequate reimbursement, as well as staffing and access issues. The overall result is compromised patient care. Community nutrition and physical activity programs supported by private philanthropy, such as the YMCA’s Livestrong program for cancer survivors, are currently filling the gap. However, reliance on charity represents a band-aid solution. Broader policy changes are needed.

Specifically, CMS should change payment rules to expand coverage for MNT across a broader array of diet-related diseases, such as obesity, cardiovascular disease, and cancer. This would require coordinated efforts by multiple stakeholders, including federal/state governments, insurance companies, healthcare facilities, clinicians, and patients. Encouragingly, there is strong public support for expanding coverage for nutrition services. Moreover, despite recent federal funding cuts, MNT has consistently demonstrated cost-effectiveness and cost-savings for a range of health conditions. In the face of a growing burden of diet-related diseases, expanding investment in nutrition is a strategic and necessary step toward reducing long-term healthcare costs and improving population health.

Author 
​Anthony Zhong is an MD-MPH candidate at Harvard University. He is passionate about strengthening primary health care systems, leveraging international and comparative approaches.