Reimbursement to Dietitians for Weight Management Services—
An Evaluation of Current Policy
Executive Summary
Sixty-eight percent of Americans are overweight or obese, making more than 190 million people candidates for weight management services in the United States. Obesity is a risk factor for a variety of serious chronic conditions, such as type 2 diabetes, cardiovascular disease, and some cancers. Obesity-related conditions are also major causes of death. Additionally, many of these conditions are
preventable through lifestyle changes that promote weight loss. Not only does obesity cause many deaths in the US, but obesity also increases healthcare costs dramatically. Overweight and obesity cost roughly $147 billion per year currently and these increased expenditures are unsustainable in the long-term.
The standard of care for treatment of adult overweight and obesity, as found in the National Guideline Clearinghouse, consists of evidence-based clinical practice guidelines for registered dietitians (RDs) to provide effective weight management programs. Modest weight loss and long-term maintenance of loss are the goals of adult weight management programs. A weight loss of 5-10% of initial body weight has been shown to improve patient outcomes, such as decreased hemoglobin A1C, decreased blood pressure, and improved HDL and triglycerides. In 2002, the Diabetes Prevention Program provided compelling evidence for delay or prevention of type 2 diabetes through modest weight loss, which was achieved through changes in eating habits and physical activity. Registered dietitians played a key role in this study, coaching participants in lifestyle change and ultimately results of the study demonstrated that modest weight loss can reduce incidence of diabetes by 58%.
This policy brief offers an evaluation of existing policy on reimbursement to registered dietitians (RDs) for adult weight management services. Private insurance plans are described and compared to the standard of care. Additionally, barriers that exist in increasing the role of the dietitian in these services are uncovered. Ideally, registered dietitians would facilitate weight management programs in
communities to help adults lose weight, but currently, numbers of adult weight management programs are low and few dietitians are being reimbursed. After uncovering the barriers that exist upstream of reimbursement, key recommendations will be described for RDs to take action to eliminate these barriers.
Introduction
This policy brief offers an evaluation of existing policy on reimbursement to registered dietitians (RDs) for adult weight management services in
order to discover the barriers that exist in increasing the role of the dietitian in these services. Ideally, registered dietitians would facilitate weight management programs in communities to help adults lose weight, but currently, numbers of adult weight
individuals that need to achieve a more healthy weight. The 2011 F as in Fat report, provided by the Robert Wood Johnson Foundation (RWJF) and Trust for America’s Health (TFAH), provides eye-opening statistics. Rates of obesity increased in 16 states over the past year and no state saw a decrease.1 This brief looks at how dietitians are being reimbursed for the treatment of adult overweight and obesity. As this brief uncovers the barriers that are at play, recommendations for eliminating these barriers will help registered dietitians begin to take an active role in weight management services and be reimbursed for the services. It is imperative that overweight and obese adults have access to weight management services provided by dietitians due to the high prevalence of obesity in the United States.
This brief begins by describing the overweight and obesity problem, bringing attention to the number of adults that could benefit from weight management services, why weight management services are important, and equally important, why registered dietitians should be involved. A description of the current standard of care or treatment for overweight and obese adults follows. This includes the evidence-based clinical practice guidelines described in the National Guideline Clearinghouse, as set forth by the Agency for Healthcare Research and Quality (AHRQ). These guidelines are formulated by expert consensus after the body of evidence has been analyzed. Each recommendation is classified with a grade to indicate how strongly the evidence supports it as an effective treatment for adult overweight and obesity.
A description of the current policies or insurance coverage for adult weight management services will also be provided. Policies
described will include medical insurance plans that provide coverage for weight management services for adults aged 20-64 that are overweight or obese. The standard of care guidelines and current policies will be compared to identify gaps or deficiencies in policy. Also, the brief will uncover barriers that exist upstream of
reimbursement of RDs. These barriers stand in the way of RDs being involved more frequently in adult weight management services. These barriers are grouped into categories. Some barriers found in this process are related to providers, while others are related to individuals and dietitians. Policy implications will describe potential consequences to changes in policy, and finally, key
recommendations are provided for the registered dietitian as a tool to make more of a public health impact.
The Problem
The National Health and Nutrition Examination Survey or NHANES, releases data every two years and provides a way to track trends for overweight and obesity status for the United States. According to age-adjusted rates for 2007-2008, for adults aged 20 and over, 33.8% are obese and 68.0% are
overweight or obese.2 During this time period the obesity prevalence for men was 32.2% and 35.5% for women.2 More specifically, rates of obesity in the 20-39 age range are slightly less than the rate for the 40-59 age range, demonstrating that people tend to gain weight during these years. 2 This trend for age is seen in both genders. Whites have the lowest rate (31.9%), followed by Hispanics (34.3%), Mexican Americans (35.9%), and the highest rate is seen in non-Hispanic blacks (37.3%).2
graduated from high school (30.4%), and those that went on to college (29.6%), and the lowest rate was seen in those that graduated from college (21.5%).1 A very similar trend is seen with income.
Generally, rates of obesity decrease as income increases. The trends that tend to be found with ethnicity and gender indicate that health disparities continue to occur.
Why is This Important?
Obesity is a risk factor for a variety of serious chronic conditions, such as type 2 diabetes, cardiovascular disease, and some cancers.3 These conditions are major causes of death. Additionally, many of these conditions are preventable through lifestyle changes that promote weight loss. Excess weight is also associated with gall bladder disease, osteoarthritis, sleep apnea, decreased mobility, and social and work discrimination.4 Achieving modest weight loss can improve health outcomes. Modest weight loss is generally a loss of 5-10% of initial body even though this may not get an individual into the
classification for healthy weight. The Centers for Disease Control and Prevention (CDC) states “even a modest weight loss, such as 5-10% of your total body weight, is likely to produce health benefits, such as improvements in blood pressure, blood cholesterol, and blood sugars.”5 The Look AHEAD study, an observational study with 5,145 participants, provides evidence of improvements in these CVD risk factors. When participants lost between 5-10% of initial body weight, there was a decrease in hemoglobin A1C of 0.5%, a 5 mmHg decrease in diastolic blood pressure, a 5 mmHg in systolic blood pressure, an increase of 5 mg/dL in HDL cholesterol, and a 40 mg/dL reduction in triglycerides. When participants had larger weight losses, greater benefits were seen in cardiovascular risk factors.5
Diabetes is possibly the one chronic disease that is most closely associated with obesity. The landmark National Institutes of Health/Centers for Disease Control Diabetes Prevention Program is one study that provides evidence of reduced incidence of diabetes through weight loss.6 In fact, through the Diabetes Prevention Program, nutritional and behavioral counseling of overweight patients in the study provides evidence that through a 7% weight loss, achieved through changes to diet and exercise, the incidence of diabetes can be reduced by 58% and even pharmacologic treatment was not as effective at preventing diabetes in this population.6 In conclusion, weight management services could benefit more than 190 million American adults that are overweight or obese by helping these individuals lose a modest amount of weight, thereby improving health outcomes.
Costs Associated With Obesity
Most obesity-related health consequences previously mentioned are chronic diseases that require medical care over a long period of time. Over the past decade, annual medical expenditures that are directly related to obesity have doubled. These estimates come from a study at RTI International, the Agency for Healthcare Research and Quality, and the CDC. The estimated annual cost of obesity may be as high as $147 billion per year.7 The results also indicated
Registered Dietitians
Weight management services provided by RDs are one solution that exists to assist individuals with weight loss. RDs are nutrition experts that are trained to provide medical nutrition therapy in the form of counseling, either one-on-one or in a group setting, on a variety of nutrition-related conditions. RDs are able to work as part of the healthcare team to improve the overall health of individuals by providing weight management services to overweight and obese patients. According to the Institute of Medicine, “the registered dietitian is currently the single identifiable group of healthcare professionals with standardized education, clinical training, continuing education and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy”.8 RDs have demonstrated success in the past as the provider for weight management services.
In the Diabetes Prevention Program, the lifestyle coaches were usually RDs.9 The lifestyle coaches met with participants individually to deliver a 16 week lifestyle change curriculum. After this period of time, lifestyle coaches met with participants for group classes on a monthly basis and contacted all
participants on an individual basis each month as well. Lifestyle coaches were encouraged to change the frequency of contact with participants as needed to help them reach weight loss goals and overcome obstacles. The coaches utilized many different strategies to tailor the intervention for each individual including additional telephone contact, a buddy system, structured menus and meal replacements, incentives, and subsidizing gym memberships. The results of this study indicate that lifestyle changes are more effective at preventing diabetes than medications and dietitians played a key role in the overwhelming success of this study.9
Weight loss is most successful when RDs are part of a healthcare team. One of the reasons for this is that the care the individual receives is more comprehensive with collaboration between provider and dietitian. One study by Welty et al, in 2007 looked at an outpatient clinic with an on-site dietitian that allowed for patients to see the dietitian the same day they saw the provider was presented.10 This study demonstrated that significant weight loss and maintenance of the weight loss can occur with this model of care. Patients lost an average of 5.6% of their total weight at 1.75 years and 81% maintained an average of 5.3% total weight loss at follow up at 2.6 years. These patients also had decreases in blood pressure, LDL, triglycerides, and increases in HDL.10
Standard of Care
The US Preventative Services Task Force recommends that clinicians screen adults for obesity and engage those that are obese in weight management services.11 This is the first step in the treatment of adult overweight and obesity. Thus, treatment of obesity is generally initiated during office visits with primary care physicians. One overall objective for the current standard of care for adult overweight and obesity, as stated by the National Guideline Clearinghouse (NGC), is to provide medical nutrition therapy (MNT) guideline recommendations for adult weight management that will reduce body weight, prevent further weight gain, and maintain weight loss over a prolonged period.12 These guidelines are in place for registered dietitians to clearly define evidence-based recommendations to be delivered as part of a healthcare team and to reduce variations in practice among RDs. This treatment should be
comprehensive, integrating medical, nutritional, and behavioral elements, and yet, should also be customized for the individual to provide a high quality of care. These standards are targeted to the adult patient over the age of 18, who is overweight, with a body mass index (BMI) of 25.0-29.9, or obese, with a BMI of greater than 30.12
The major recommendations from the NGC state that an individual should be classified overweight or obese through the use of body mass index (BMI) and waist circumference.12 These guidelines also state that if an individual is classified as overweight or obese, a comprehensive weight management program that integrates diet, physical activity, and behavior therapy should be utilized as this is more successful at weight loss and weight maintenance than using any one intervention component alone. The optimal length of the program would be at least six months or until weight loss goals are met, with a weight maintenance program to follow. It has been shown that weight loss success correlates with the number of contacts an individual has with the practitioner. The more times an individual can be seen, the more successful they will be with weight loss and weight maintenance. The NGC also recommends a slow, gradual weight loss, 1-2 pounds per week, and that the initial weight loss goal should not exceed 10% of initial body weight. This correlates with the definition of modest weight loss from the CDC of 5-10% of initial body weight.12
NGC guidelines declare that when an individual is classified overweight or obese, the individual should be referred to a registered dietitian and be given a nutritional assessment.12 This assessment should consist of a medical history and relevant laboratory tests to consider other existing co-morbidities, resting metabolic rate to determine estimated energy needs, comprehensive diet history including current dietary intake and readiness to change, physical activity pattern, psychosocial and economic issues that would affect nutrition therapy, and consideration of other conditions that would impact the nutrition care plan. One of these conditions might include coronary artery disease and the need to modify amount of fat in the diet would need to be considered.12
These can include counseling and nutrition education, dietary modifications, such as reduction of calories, portion control, meal replacements, changing eating patterns and amounts of macronutrients (for example, carbohydrates), physical activity, behavioral strategies such as stress management and stimulus control, and weight loss medications or bariatric surgery.12
There are very few primary care settings that offer weight management services at this time. There are a few studies that have tried to apply the Diabetes Prevention Program (DPP) principles of modest weight loss to the primary care setting. One study with nurse practitioners provided six visits with a nutritionist over a six month period.13 Another primary care study offered a more intensive treatment phase consisting of 12 visits with a health educator or dietitian over a 12 week period.14 As more of these services are offered in primary care settings, more data will be provided about feasibility and cost. Costs of primary care weight management services such as this vary as well. When primary care
providers utilize existing health care personnel, the cost will be lower. The options for obesity
treatment outside of primary care at this time range in cost as the actual treatment itself varies. Some of the available options for weight loss programs can range from $0 dollars, for Overeaters Anonymous, to thousands of dollars for commercial supervised programs with one-on-one sessions and meal
replacements.15
Policy Options
This policy brief is examining current policy or coverage for adult weight management services when provided by registered dietitians. The specific age group of interest is 20 to 64 years of age. Current policies for this range include private insurers.
Around 60% of Americans are covered by private health insurance plans that are employer-based plans. In 2009, 60.4% of adults, ages 19-64 were covered by employer-based health insurance plans, and this reflects a drop since 2007, when 64.5% of adults were covered.16 Some private
Insurer
Diagnoses Covered
RD Services
Number of Visits
Cigna18 Obesity (BMI >30), post-bariatric surgery
Individualized nutritional evaluation & counseling by a licensed health professional
Not specified, should contact insurer about specific benefits
BCBS19 Obesity, morbid obesity (based on physician diagnosis)
Individualized medical nutrition therapy, by LDN or RD
Not specified, should contact insurer about specific benefits Aetna20 Obesity (BMI>30) or
overweight (BMI 27-29) with one comorbidity
Individual, group, support group, or class
Six visits per year, with possibility for additional sessions, $750 max/yr
Although these insurers do not provide the actual reimbursement to RDs for these services, most use the Medicaid reimbursement as a minimum. Just as Medicaid providers can bill in 15 minute
increments, BCBS is structured in the same way. Reimbursement for RDs per 15 minutes for MNT is $18.92 for initial assessment and $16.51 for follow-up visits.21
As registered dietitians, providers of adult weight management services, it is important to remind those interested in weight management services to contact insurance company about specific benefits. These companies also offer other medical insurance plans that have no coverage for these services.
Additionally, even if an individual has coverage one year, the plan may change from year to year and inquiring about the specific benefits is always advisable.
Policy-Related Barriers
In the previous section, coverage for adult weight management services was examined for several private insurers. The American Dietetic Association (ADA) states that weight management treatment strategies exist but are limited by resources due to limited reimbursement to registered dietitians.22 This is certainly true. While there are a few plans providing some coverage for obesity treatment, they do not reach enough people. Considering that many adults have no medical insurance plan coverage at all and then of those that do have a plan, most do not have the top tier plans that offer obesity
treatment. One such example involves the state employees of North Carolina that are enrolled in Blue Cross Blue Shield health plans that do not have coverage for obesity treatment. This plan covers more than 663,000 adults in North Carolina.23 Blue Cross Blue Shield of North Carolina’s Blue Advantage plan, offered to individuals purchasing coverage, does include six visits to a registered dietitian for nutritional counseling per year.24 This plan is more expensive and is not offered to the large numbers of state employees. Essentially, treatment for obesity is available for some adults and not others. If an overweight or obese adult wanted weight management services and did not have coverage, the cost of these services could cost a couple hundred dollars to several hundred dollars. This is simply too much for a person to pay out of pocket to receive help with weight loss.
plan is not reaching nearly enough people and therefore, is not making a significant impact on the problem.
Barriers To Increasing RD Involvement in Adult Weight Management Services
Registered dietitians are able to provide weight management services to assist overweight and obese adults with weight loss, and yet these services are being underutilized. There are barriers to increasing the role of the RD and therefore RDs are not able to be reimbursed for these services. In this section these barriers will be described. If there are people that need weight management services and there are RDs to provide the services, the question is why individuals are not receiving the standard of care.
Provider-Related Barriers
Unfortunately, there are other barriers to increasing the role of the dietitian in adult weight
management services. When adults are seen by primary care providers for well visits, only 48.7% of them are screened for obesity by the provider through the measurement of BMI.25 This is a necessary step in classifying an individual as being overweight or obese and some individuals are being lost at this step. Statistics also show that when individuals are classified as overweight or obese by providers, they are not necessarily being referred to RDs. A 2000 report from the Institute of Medicine says that physicians routinely refer to RDs <25% of the time and even less (10%) have an RD available for
patients.8 These statistics provide some insight into the barriers that exist at this time to increasing RD involvement in weight management services.
A study on obesity management from the Albert Einstein College of Medicine in New York, from 2006 provides additional clues to the picture. Chart reviews of patients in an outpatient internal medicine resident continuity clinic had the following results showing practice behaviors of primary practice physicians in residency training:26
80% of clinic patients were either overweight or obese
21% of obese patients and 11% of overweight patients had the diagnosis documented Of the obese patients, 17% had dietitian referrals
36% had an indication in the chart of physician weight loss recommendation26
Providers are not consistently utilizing the standard of care and therefore, opportunities for counseling overweight and obese individuals are being missed, not only for the physician, but also the registered dietitian.
Helpful Strategies Identified by Family Physicians27
n=255*
Insurance coverage for obesity treatment Readily available nutrition and exercise therapists List of community resources to refer obese patients Office personnel who are sensitive to patient needs Education on effective weight loss interventions Dietitian on site
Education on motivational skills
Equipment/furniture that accommodates them Better counseling tools
Case manager to help coordinate health care Education on specific examination techniques Placing scale in private area
Reminder system for preventative exams Scheduling more complete physicals
Specialist who deals with just severely obese patients *Items are listed in order of mean rating
Patient Perspective
In the same study in New York that looked at internal medicine residents’ practices, patients were given a survey to assess their attitudes about weight loss counseling. Results indicated that 86% of obese patients wanted to lose weight, 64% wanted a dietitian referral, and 62% felt that their physician could help with weight loss. Only 10% of patients surveyed reported not wanting to discuss weight or weight loss with their physician.26 This study provides information about the patient perspective in this issue.
RD-Related Barriers
Barriers related to RDs include a lack of knowledge and a shortage of dietetic practitioners. Due to the ever-changing world of policy, registered dietitians need to maintain a knowledge base regarding policies that provide coverage for adult weight management services. Dietitians also need to keep abreast of changes in coverage that might arise from the Affordable Care Act. More preventative services will be offered through state healthcare exchanges in 2014. Finally, if more coverage is available for overweight and obese individuals to receive weight management services, will there be enough registered dietitians to provide the services? With more than 190 million Americans falling into the category of being overweight and obese, there is certainly concern surrounding having enough RDs available.
Policy Implications
Lack of policy or insurance coverage for adult weight management services is a formidable obstacle. The ideal policy would include adult weight management services provided by RDs covered at 100%. If this were the case, more patients would be interested in the services. One study that provides evidence for this involved adults with metabolic syndrome in the state of Washington. One hundred and fifty three adults were administered a telephone survey that provided the scenario that their
insurance coverage for weight management services would increase from 10% to 100%.28 A threefold increase in women and a sevenfold increase in men indicated they would be interested in participating in a weight management program within the next 30 days.28 Insurance coverage of weight management services plays a huge role in the decision-making process for overweight and obese individuals.
Insurers have also considered outcome-driven reimbursement to participants. A study was conducted by the Clinical Nutrition Research Center in Birmingham, Alabama examined whether insurer-based reimbursement would improve participation in a group lifestyle-based weight management program and weight loss outcomes.29 Obese participants who had the potential for reimbursement (group A) were compared with a group that had no possibility for reimbursement (group B). Those participants in group A attended significantly more classes and lost more weight than group B. 56% of those in group A lost greater than or equal to 6% of body weight, while only 20% of group B subjects did.29 This study provides evidence that participants in adult weight management programs can be motivated by reimbursement from insurers.
In order for insurers to cover weight management services 100% for individuals that are overweight and obese, treatment would have to be cost effective. Although this would increase cost to the insurer in the short term by helping individuals to lose weight, it is thought that long term costs would be less due to improved outcomes for the individuals who have lost weight. In the Diabetes Prevention Program, a rigorous cost-effectiveness analysis was done and the cost of the intensive behavioral treatment utilized was approximately $1,200 per person for the first year in the program.30 While this is too costly for private insurers, there are many parties that are looking into ways to accomplish the same with less expense. One clear way to reduce cost to insurers is to offer weight management services in the group setting rather than one-on-one counseling. Another way to reduce costs, utilized by TRICARE’s
Policy Recommendations
The Affordable Care Act is changing healthcare for the future. There are many changes that are already occurring. At this time, states are receiving federal grants to create state health exchanges. State regulators are structuring these exchanges with essential benefits, certain clinical preventative services that will be covered 100%. This makes now an ideal time to work towards more coverage for adult weight management services provided by the RD. Whether
the RD is in the physician practice providing counseling or in another setting in the community providing services, weight management services could be standard practice for adults that are overweight and obese. An ideal situation would be for private and public sectors to work together to educate private insurers on the benefits of adult weight management services, as well as come up with strategies to provide the services in the community so that patient referrals can take place and adults can be enrolled in effective programs. Even though this is a perfect time for insurance coverage to change for adult weight management services, it will not happen overnight.
There are a couple of steps that can be taken by RDs now. Key recommendations would include:
1. Partnerships between providers and registered dietitians need to occur. This would provide more visibility of the role of the RD and providers could be educated about weight management programs, their structure and efficacy. The partnership would ensure that when adults are classified as overweight or obese, they are referred to a weight management program led by an RD.
2. Registered dietitians working in private and public health care centers must advocate for adult weight management programs. If no such program exists in an area, dietitians should educate community health leaders of the importance of such programs. Dietitians should also take a leadership role in planning these programs so that evidence-based guidelines are used and they are cost effective for the organization.
3. Registered dietitians and providers should track adult weight management program results and be prepared to use the results to educate private insurers. If successful weight loss is documented, using evidence-based guidelines, and presented by the healthcare team to an insurer, policy change may be fast-tracked. This may not only help change coverage amounts, but also the types of programs that should be covered. In fact, BCBS of North Carolina has used this type of practice-based evidence in the past.
4. Registered dietitians must make all providers in a community aware of the resources for adult weight management services. Whether this is a list of registered dietitians or programs that help facilitate weight loss with a healthcare team, dietitians should ensure that providers have places to refer overweight and obese adults.
Registered dietitians are the primary nutrition health professionals and are valuable members of the healthcare team. They will only be recognized as such when they can demonstrate their capabilities to the healthcare team through weight loss results and improved patient outcomes. When overweight and obese adults can have access to weight management services on a large scale and get the assistance they need for modest weight loss, weight-related chronic disease will decrease, as well as healthcare expenditures. Obesity is threatening America’s future. Now is the time to act. Registered dietitians can play an important role in reducing the prevalence of obesity and therefore, have a significant public health impact in the communities in which they live and work.
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