Dietitians Using Medicare Reform to Monopolize Hospital Nutrition Services

Girl-eating-hospital-food-002It won’t help hospital food, already notoriously bad, to outlaw advice from the most qualified nutritionists. Action Alert!

Medicare claims to be reforming some of its rules in order to get rid of unnecessary or burdensome regulations. But this has created a window for the dietetics lobby to insert language that will give them a monopoly over hospital diets. This is the very definition of a sneaky maneuver—almost no one would think to look for this change until it had already passed. Happily, we did!

The Federal Register announced the various reforms to Centers for Medicare and Medicaid Services (CMS) rules earlier this month. Buried deep inside the new regulations are two sections: Food and Dietetic Services and Privileges for Registered Dietitians (RDs). This would revise the requirement that a therapeutic diet be prescribed only by the practitioners responsible for the care of the patient—a revision we agree with, since few physicians know anything about nutrition. But it would be expanded to include only Registered Dietitians (not Certified Nutrition Specialists, many with Master’s degrees and PhDs, or other highly qualified nutrition professionals) to prescribe a therapeutic diet. This rule specifically deals with special diets for patients; RDs already have a grip of iron on regular hospital food—though not by law!

CMS writes—though it could very easily be the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) talking—“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.” It adds that RDs with prescription privileges “would also be able to provide medical nutrition therapy and other nutrition services at lower costs than physicians as well [sic].” Note the co-opting of the terms “medical nutrition therapy” and “nutrition services” for RDs, even though RD’s are only required to have a college degree, and the tortured government logic that creating a new monopoly will reduce costs.

The US Department of Labor places hospital diets under the control of both dietitians and nutritionists. Medicare rules should follow the same guidelines.

Securing a piece of the Medicare pie is part of the dietitians’ strategy at the state level as well. Medical nutrition therapy (MNT) services are covered under Medicare part B for people with diabetes. Federal rules state that RDs or qualified nutrition professionals may provide services so long as they meet certain education and experience requirements and have been certified by a national nutrition organization. However, if an individual state has a licensure policy in place, then only the licensed individual can receive reimbursement. That is why RDs are trying to get the states to pass laws making dietitians the exclusive providers of licensed nutrition services—it creates a separate tier for themselves so they can secure MNT reimbursement through Medicare.

The folks at AND/ADA are speaking out of both sides of their mouth about licensure. On one hand, they say they need a monopoly on scope-of-practice laws so they can be reimbursed by Medicaid and Medicare. But in the document that they submitted to CMS, they argue that “licensure is not a federal requirement” for dietitians to be part of a “medical staff” and therefore receive CMS reimbursement:

Licensure is not a federal requirement; it is only required for practitioners in those states with laws requiring licensure. Federal regulations specific to dietitians similarly have no independent licensure requirement. In section 482.28(a)(2) of the hospital [Conditions of Participation] defining a “qualified dietitian” in the hospital setting, “[q]ualification is determined on the basis of education, experience, specialized training, State licensure or registration when applicable, and maintaining professional standards of practice.”

Sorry, dietitians, you can’t have it both ways!

Here are the monopolistic licensure bills currently in state legislatures:

  • Indiana: HB 1272. We recently sent special action alert to Indiana residents about this.
  • West Virginia: HB 2533. We will be emailing a special action alert to WV citizens soon.
  • New Jersey: AB 2182/ SB 833. The bills are still “alive” but in a holding pattern.
  • In Illinois the law is much improved. We were able to get the Illinois legislature to replace the state’s ten-year-old monopolistic dietitian law to include certified nutritionists. The new law is currently in the rule-writing phase. We will keep you updated.

Action Alert! CMS is asking for public comments on the new Medicare rule. Tell them that while we agree that hospital diets should be open to nutrition professionals and not solely under purview of physicians, we cannot support Medicare rules that create a monopoly for RDs at the expense of often better-qualified nutrition professionals. Send your message today!

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    1. Please don’t lump all dietitians in the same boat. There are many dietitians that specialize in different fields that are top notch. For example, many dietitians have masters degrees in sports nutrition and are the dietitians for professional sports teams around the country. If you are critically ill in the hospital and need someone to calculate your tube feed or parenteral nutrition, I can’t think of anyone I’d rather have do that than a dietitian. One wrong decimal point and someone could be history. Same goes for dialysis clinics. Dietitians that specialize in renal nutrition are exceptional. There are dietitians that specialize in celiac disease that are partnering with physicians that are top celiac researchers and helping to bring celiac awareness to the U.S. and helping bring about major needed changes in that arena. Others specialize in immunology and food sensitivities and work with patients that have ulcerative colitis, crohn’s and other serious conditions. It’s important in these cases to have a good background in biochemistry, anatomy and physiology, etc. which dietitians do. I have a master’s degree in nutrition and post-graduate training in food sensitivities and immunology. I get exceptional results with my clients that have chronic inflammatory conditions and I don’t appreciate blanket statements that say that we are all worthless.

  1. Although I agree that in many cases, there are qualified nutritionists that do have master’s degrees or PhDs, there are many nutritionists that don’t have a degree at all. In a hospital environment, where patients are critically ill, it is in the best interest of the patient to have someone that has extensive education in anatomy & physiology, biology, biochemistry, and training on calculating enteral feedings for patients. One wrong calculation could cause significant harm or even death.

    1. Yes give them their licence so they can feed sick patients white bread, cows milk, GMO’s and Aspartame. We would not want them to promote good spring water. Organic meats, fruits and vegetables. Yes their education is great! I am sure most patients will return again.

      1. Please tell me a hospital that has the budget for Organic Products, etc. RDs as well as other food service managers do the best with what they are alotted the vast majority of the time. When you have the CEO of your company breathing down your neck to produce more and more with less money, organic apples may not be at the top of their list.
        It is upsetting that groups of individuals that base their careers on helping America achieve better health would stoop to bashing each other. Most RD’s have no problem with nutrition professionals that have the proper education (Master’s, PhD, Etc.) but even the salesmen at supplement stores call themselves nutritionists. Should they be allow to recommend a Tube Feed order in a hospital setting? If there were a hospital allowing it, I would avoid it at all costs.

      2. Narrow minded, judgemental comment. Shame on you. This is why it is extremely important that we allow only those educated in a minimum of four maths and nine sciences including medical nutrition therapy through an accredited four year program along with a one year internship. I am sure you have no idea what it takes to provide enteral or parenteral nutrition accurately or to prescribe for a patient with Crohn’s disease or colitis or any other critical conditions. Do you have any idea about balancing IV iron and erythropoientin, bone mineral and PTH in ESRD patients? Not something learned on the internet or in a newsletter. I do not condemn all nutritionists nor do i group them all in the same catagory as you do with RD’s. There needs to be a difinitive line drawn between the qualified and the quacks.

    2. I believe that if we are talking about hiring an individual who is either a CNS or CCN, the issue of qualifications would be moot since they are required to have at least a Master’s degree from an accredited university and sit for a national exam. However, I am not certain if this requires practical experience. This would eliminate the CN’s who come from any of a number of backgrounds, many of whom are highly qualified, but as you said, many are not qualified to be working in a hospital setting.
      While I agree that RD’s can be a stodgy bunch, and am appalled with the underhanded tactics of their association, I am frustrated at the tendency of some to sink to name calling and proclaim blanket statements. This is an excellent way to decrease respect for the nutritionist community. Some RD’s are attempting to help the cause and get qualified nutrition specialists access to nutrition care everywhere. We are working from the inside of their organization as well as from the outside with you. Some of us RD’s have gone on to educate ourselves in other settings and expand our knowledge of maximizing health and not just treating disease. Please be careful about alienating those whom you don’t know by issuing poorly thought out statements.

  2. I would be happy to send the protest letter to which the “take action” button is linked, except for one thing–I don’t know what name to put in the brackets. The form letter begins, “Dear [Decision Maker],”–what name do I put there?
    Please DO something! I can’t send an email to “Dear [Decision Maker]”…!

    1. Hi Gertrude–Thanks for your comment! Our software will automatically populate the “Decision Maker” field with your Congressional representative when your message is sent.

  3. As a TCM practitioner trained in Chinese nutritional therapy (during an extensive and detailed five-year Oriental Medicine curriculum), I am outraged at the thought of RDs being the only “professionals” allowed to provided ‘medical nutrition therapy.’ Chinese nutritional therapy (a branch of Chinese medical theory) uniquely differs from modern Western nutrition in that it determines the energetic and therapeutic properties of foods rather than analyzing them solely according to their chemical constituents. Chinese nutrition also takes into consideration such factors as the person’s body type, age and vitality level, geographical location, yearly seasonal influences and the method of preparation in determining the appropriate diet. The advantage of this type of nutrition lies in its ability to adapt to the changing needs of an individual. Rather than focusing on treating a particular disease, the whole person and their interrelated biochemical and bio-energetic systems are addressed. I have over 3000 hours of clinical and didactic training, which means I am more than qualified to provide ‘medical nutrition therapy’ to patients – whether in a hospital setting or in a private clinic.

    1. To change the wording of this bill to include the generic “Nutritionist” would clearly be a detriment and potential danger to high acuity hospitalized patients. Unfortunately, the title “Nutritionist” may be assumed by ANYONE without any concrete proof of training, In PA, where there is licensure, someone without an RD can become licensed if they can prove they have equivalent education – to which RD’s do not object. If educated non-dietitian nutritionists would ban together and insist that the title “Nutritionist” had real educational requirements, it would be much easier for those Nutritionists who (like you) actually have a legitimate background to achieve the recognition they deserve. Sadly it is not those like you who I fight against being allowed to “consult” my patients – it is those who read a cookbook, a “health” magazine and go to a lecture given by someone else without legitimate credentials, who then insist my dialysis patient should be eating cantaloupe and tomatoes and taking a proprietary supplement that only they sell that I vehemently oppose.
      It is my greatest wish that licensure is passed in every state. Licensure is to protect the public and allow only those who have credentialed, legitimate training be able to provide Medical Nutrition Therapy. Even you must admit that the title Nutritionist is assumed by many incompetent practitioners. Please clean up your field before you insist on limiting ours.

    1. Its not bashing dietitians… its the fact that they want to grab a lock out of possibly more enlightened nutritional information. Most dietitians are trained to an orthodoxy which is outdated scientifically and actually causing disease. They should not be allowed the bully pulpit.

  4. Linking the RDs to the quality of the hospital meal is unfair. It’s not the dietitians that are the driving force behind the quality of hospital meals. Show me a “nutritionist” who can feed a hospital with 500 beds on an average hospital food service budget. It’s an abomination – but since the processed food wave of the 20th century – hospital directors still have the mentality that food and its production should cost as little as possible. Hospitals’ board of directors just don’t allocate enough funds for foodservice (for both quality food purchasing and to pay qualified chefs (most RDs are not chefs – they are medically trained nutritionists) and staff). It is nearly impossible for dietitians who are involved in hospital food production (because admit it – no nutritionist takes on a hospital food management job because it’s too darn hard) to implement changes. I know chef/nutritionists here in CA who have worked over 10 years to improve hospital food, and only have been able to make tiny, incremental changes. But they are doing it, they are ACTUALLY doing the work, the hard work of changing the system. But all you guys do is point fingers and whine. Pull up your sleeves and collaborate. It’s easy to tell affluent privileged people to eat organic food, but dietitians work in the trenches with those less fortunate to help them navigate this country’s messed up food system and who try to change the system from within. It’s the lack of dedication of adequate funds to the foodservice part of the hospital operation that drives the bad food, not the clinical dietitian on the hospital floor that councils patients and helps get calories into the critically ill.

  5. The system of feeding our population is messed up BIG time. It’s not about nourishing our communities, but rather, about making $. The funds devoted to running hospitals, and especially schools, is appalling. People say all the time that the food we feed kids in school is terrible. And, you know what? A lot of it is! The foodservice systems are set up such that the cheapest made food, therefore, the cheapest to purchase, is bought to maximize profits. And in school’s case, they have to buy the cheap food because they run as an independent business. Yup, that’s right. School cafeterias often pay rent to be in the school, they pay their own employees and electric bills out of $ generated from the minimal Federal reimbursement for meals sold to kids in poverty, and any other sales (which is why historically schools have sold cheap crap like soda and chips). The tied is turning, thankfully, but very slowly (of course! nothing in government happens fast). AND, it is the hard work of many RDs and other health professionals that is shaping this change.
    The issue with the word “nutritionist” is it’s too broad. A weekend certification does NOT qualify you to prescribe therapeutic diets. High potassium fruits and veggies recommended to someone with chronic kidney disease could kill them. Point blank! There NEEDS to be some assurance that if in depth, personalized diet plans are being recommended, that the nutritionist truly know what they are doing.
    General nutrition information can be shared by anyone, because after all, it’s that same general nutrition info that can be found in a million place (books, website, blogs, etc). RDs can not lay claim to this kind of info. BUT, complicated food recs for complicated human bodies need to be done by some with extensive and far reaching educational backgrounds, whether that person be a RD, or a PhD in Clinical Nutrition, or whatever….as long as the education is there….that’s the point!
    Last point- there are a lot of RDs who get other specialty certifications in more complementary areas. There is a group called Dietitians in Integrative and Functional Medicine. They have a wealth of knowledge in this area. And, I can tell you, there are a lot of medical practitioners including doctors, nurses, PAs, etc that poo-poo a lot of the areas these RDs cover….mainly because it’s not in line with the current industry standard protocol, or whatever. So, there are plenty of RDs on both sides…

    1. Forgive if this is a re-post. I agree that Nutritionist is too broad a term and for the sake of the patients a standard must be developed and maintained. However, The death grip that The American junk food Assoc has on the State legislators mandating a “recognized School” before sitting for the State exams is appalling. ANYONE should be able to take the exams with or without attending the “right” school. Pass or Fail. If the test is the true measure of Knowledge, why does the ADA turn the screws to prevent the test from being offered to EVERYBODY.

  6. I am and RD but practice well outside the dietetics realm. I do not object to the RDs being the exclusive caregivers of nutritional meals in clinical settings. We can always lobby for them to produce healthier meals instead of the ones currently mandated by hospital administrators willing to do tests that cost thousands of dollars but demand meals that cost penniwes..
    However, their intent is to then be the only purveyors of nutritional advice in all areas of practice outside the hospital. I think that any person should be allowed to sit for a test in any state if they have any bachelor’s degree in the biosciences in order to be licensed. Doctors, nurses, chiropractors, dentists, physical therapists, naturopaths, biochemists, etc. should also have to sit for the test to practice nutrition professionally. This is a complex issue and I take it as a serious one if any group wants a monopoly on delivering services and do not want to associate myself with a group having that intent

  7. Well, I guess I made the right decision becoming a personal trainer full time versus going back to college for the RD program.

  8. There seems to be a big misunderstanding. There are hospitals in place now that have acupuncturists present in operating rooms. The use acupuncture in place of anesthesia during heart surgery is growing. Researchers are recognizing the benefits of utilizing acupuncture as anesthesia with open heart surgery ( The terms nutritionist and dietitians are also starting to merge.
    RD’s do not claim that they are nurses or complementary alternative health experts. RD’s do refer their patients to other experts who are members of Alliance for Natural Health, nurses or specialized doctors. The RD does not strive to practice in a bubble, all alone.
    How about if we create this web of healthcare professionals which places clear scopes of practice built on years of medical experience, practice and science based education that each professional would have accrued? This would turn our attention to developing a more complete and comprehensive team designed for patient care. There already is an underlying understanding and sense of place that each of these experts have. The challenge is to turn our focus to the patient. If a patient is receiving treatment from a healthcare professional, it seems only logical to have that expert licensed to not only protect the integrity of the profession, but to protect the patient and future patients from malpractice.
    There are numerous realms in community services, skilled nursing homes to clinical hospital settings. Each of the health care professionals regardless of setting would have a solid background in science: biochemistry, nutrient metabolism, human biology, physiology, anatomy, organic and inorganic chemistry, evidence based therapeutic diets, and environmental nutrition to name a few. A yearlong internship, which is precluded by a didactic program, specialized in the field of interest. These therapeutic diets are supported by extensive scientific evidence on its effectiveness at improving health and ethical deliverance of care to the patient.
    It is important to hold practicing professionals in settings liable for patient care. I agree that enteral feeding is best taken care of by the RD along with the pharmacists as Susan had stated. Knowing that that type of care can be fatal is pertinent to license this person to hold them liable for any malpractice that may occur. This person could leave that hospital and get hired at another hospital and continue malpractice. If these…

  9. There is a new wave of younger, more politically aware dietitians who are rising up to fight against some of their predecessors’ choices. [See: Dietitians for Professional Integrity.] Out with the old, in with the new. We are looking forward to expanding the educational requirements to a masters degree in the next 10 years. RDs are SUCH a diverse group of practitioners. There is no “nutritionist” in my community threatening my job and my relationship with the physicians in the area (so not feeling particularly threatened by this conversation). I am sure many RDs feel the same way.
    In fact, I’m not even against people with MASTERS or PHDs in nutrition being able to sit for the board exam to become a dietitian. I think that’s a great idea, in fact. However, I’d agree with the concensus on this board that what we’re really trying to protect patients from are “weekend nutritionists” trying to practice medical nutrition therapy. If a patient would like to seek out alternative therapies, such as seeing a Chinese herbalist, I truly hope that this will not be considered illegal, that would be a disservice to that patient seeking alternative therapies.
    However, yes, in the case of hospital diets, most “nutritionists” would have no business in that arena, possibly putting the medically complex patient at risk. However, if it was someone who could prove they had just as much if not MORE training than a dietitian, and pass the board exams, I think there could be room for that. It won’t be the majority of nutrition practitioners, but for the people with THAT much zeal for nutrition, let them take the exam.

  10. “Nutritionists” and other people who think they should be the nutrition experts have an issue with RDs being the only ones allowed to provide MNT.
    To that group, tell me what MNT means without having to look it up, and if you know what it means, what about NCP? And describe its steps.
    No…?? Didn’t think so.
    We’re way more qualified and knowledgeable about treatment of diseases than anyone else. Don’t fool yourself into thinking otherwise.
    Go back to school and become an RD if you want to be a real authority on nutrition.

    1. First of all a State License should be understood as the qualifier for the profession. Whom ever meets State academic and training requirements for nutrition practice therefore is qualified. The AND/ADA is just trying to find a way to make MNT and nutrition practice exclusive to RD’s. They also want to be above State level requirements because they know CNS, Masters, PHD’s along with RD”s Share the Same State License, which gives equal rights to practice MNT by law. Secondly it would be ludicrous for RD’s to compare their entry level baccalaureate training versus Advanced Degree level CNS trained Nutrition professionals. Since when is an entry level degree more qualifying than the Advanced level degree in the same profession? That is like saying the PA is more qualifying than the MD. AND/ADA just feel if they can beat people to the legislative punch, they can sneak in their exclusive language.

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