Medical Nutrition Therapy for Patients with Non–Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions

      The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] . There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published.
      Chronic kidney disease (CKD) currently affects approximately 15% of the US population or 30 million US adults,

      Centers for Disease Control and Prevention. National chronic kidney disease fact sheet, 2017. https://www.cdc.gov/kidneydisease/pdf/kidney_factsheet.pdf. Updated 2018. Accessed March 6, 2018.

      but incidence is projected to increase over the next 2 decades due to the ongoing obesity epidemic and the aging of the US population.
      • Hoerger T.J.
      • Simpson S.A.
      • Yarnoff B.O.
      • et al.
      The future burden of CKD in the United States: A simulation model for the CDC CKD initiative.
      Almost half of all US adults aged 65 years and older are predicted to develop CKD during their lifetime.
      • Hoerger T.J.
      • Simpson S.A.
      • Yarnoff B.O.
      • et al.
      The future burden of CKD in the United States: A simulation model for the CDC CKD initiative.
      The economic impact of CKD is substantial. Despite the fact that end-stage renal disease (ESRD), the most severe stage of CKD requiring kidney transplant or dialysis, is experienced only 650,000 US persons, the Medicare costs alone exceed $33 billion annually.

      US Renal Data System Annual Data Report 2013. Chapter 11. Costs of ESRD. www.usrds.org/2013/view/v2_11_aspx. Updated 2016. Accessed August 19, 2016.

      Health care costs for earlier stages of CKD, when dialysis or transplantation is not required, exceed those for other expensive chronic conditions such as stroke and cancer.
      • Small C.
      • Kramer H.J.
      • Griffin K.A.
      • et al.
      Non-dialysis dependent chronic kidney disease is associated with high total and out-of-pocket healthcare expenditures.
      Because health care costs increase more than twofold as CKD advances to more severe stages, slowing or preventing CKD progression will substantially reduce health care costs.
      Nutrition management remains among the most important interventions for slowing CKD progression and delaying or preventing ESRD.
      • Kalantar-Zadeh K.
      • Fouque D.
      Nutritional management of chronic kidney disease.
      Healthy lifestyle habits and the maintenance of a healthy weight play a key role in preventing type 2 diabetes and hypertension, the two major causes of CKD.
      • Garrison R.J.
      • Kannel W.B.
      • Stokes 3rd, J.
      • Castelli W.P.
      Incidence and precursors of hypertension in young adults: The Framingham Offspring Study.
      • Hu F.B.
      • Manson J.E.
      • Stampfer M.J.
      • et al.
      Diet, lifestyle, and the risk of type 2 diabetes mellitus in women.
      Once kidney disease is established, dietary modifications such as decreasing intake of animal protein, phosphorus additives, and salt and increasing intake of fresh fruits and vegetables may slow kidney disease progression. However, dietary modifications for slowing kidney disease progression require patient education and close monitoring due to risks of malnutrition and hyperkalemia. Medical nutrition therapy (MNT), the individualized nutrition assessment, care planning, and dietary education provided by a registered dietitian nutritionist (RDN), remains an effective intervention for slowing CKD progression and delaying or even preventing ESRD. In 2000, the Institute of Medicine recommended MNT to patients with several diseases, including diabetes mellitus and/or nondialysis-dependent CKD because evidence demonstrates that MNT improves clinical outcomes and could decrease costs of care.

      Institute of Medicine. The role of nutrition in maintaining health in the Nation’s elderly, Washington, D.C. National Academy Press. 2000.

      Currently, Medicare Part B covers MNT for patients with nondialysis-dependent CKD with no cost sharing. Many state Medicaid programs and private insurers also offer coverage for MNT for CKD. Despite the benefits of MNT on CKD progression and potential reductions in cost of care, the overwhelming majority of adults with CKD never receive MNT and most adults with CKD remain poorly informed of how diet influences disease management and progression. Although research specific to underuse of MNT services by RDNs for patients with CKD remains scant, anecdotal reports, along with initial research on low utilization of diabetes self-management training (DSMT), have identified potential barriers that may also hold true for patients with CKD.
      • Siminerio L.M.
      Implementing diabetes self-management training programs: Breaking through the barriers in primary care.
      • Balamurugan A.
      • Rivera M.
      • Jack Jr., L.
      • Allen K.
      • Morris S.
      Barriers to diabetes self-management education programs in underserved rural Arkansas: Implications for program evaluation.
      • Powell M.P.
      • Glover S.H.
      • Probst J.C.
      • Laditka S.B.
      Barriers associated with the delivery of Medicare-reimbursed diabetes self-management education.
      • Peyrot M.
      • Rubin R.R.
      Access to diabetes self-management education.
      • Eakin E.G.
      • Bull S.S.
      • Glasgow R.E.
      • Mason M.
      Reaching those most in need: A review of diabetes self-management interventions in disadvantaged populations.
      These potential barriers for MNT services for patients with CKD include low awareness of benefits by patients and clinicians, lack of availability of services from RDNs who may perceive the process of Medicare enrollment/insurance credentialing and billing as being burdensome and complex, inconsistent coverage for MNT services for CKD by non-Medicare payers, and patient travel and time issues to receive the services. In this review, we examine how diet may influence CKD progression and the role of MNT to improve health outcomes. We also examine reasons for low use of MNT services provided by RDNs for patients with CKD and potential solutions for increasing MNT use.

      CKD Is a Nutrition-Related Health Problem

      CKD is classified into five G stages based on the estimated glomerular filtration rate (eGFR) using the serum creatinine levels measured with any metabolic panel.
      KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
      CKD G stages 1 and 2 are present when eGFR levels are ≥60 mL/min/1.73 m2 in the presence of other kidney abnormalities such as increased urine albumin excretion, a marker of kidney disease. Stages G3 to G4 are present when eGFR is between 59 and 15 mL/min/1.73 m2 and stage G5, the most advanced stage, is present when the eGFR falls below 15 mL/min/1.73 m2 or when renal replacement therapy such as dialysis is required.
      KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
      The 3 albuminuria or A stages additionally stratify CKD, allowing for more accurate risk prediction when added to the G stages. The albuminuria stages are defined using albumin-creatinine ratio with levels <30 mg/g for A1, 30 to 299 mg/g for A2, and ≥300 mg/g for A3. For a person with CKD who has not yet progressed to kidney failure, diet is a modifiable factor that may be altered at low cost. Thus, nutrition management should be a first-line intervention. Many factors in a patient’s diet can influence CKD progression. For example, the Western diet is characterized by high intake of red meat, animal fat, and salt combined with low intake of fresh fruits and vegetables
      • Lin J.
      • Fung T.T.
      • Hu F.B.
      • Curhan G.C.
      Association of dietary patterns with albuminuria and kidney function decline in older white women: A subgroup analysis from the Nurses' Health Study.
      and contains a high amount of highly processed foods and saturated and trans fats.
      • Odermatt A.
      The Western-style diet: A major risk factor for impaired kidney function and chronic kidney disease.
      Individuals with dietary patterns that reflect a typical Western diet are more likely to have moderate to severely increased levels of urine albumin excretion, and a rapid decline in eGFR.
      • Lin J.
      • Fung T.T.
      • Hu F.B.
      • Curhan G.C.
      Association of dietary patterns with albuminuria and kidney function decline in older white women: A subgroup analysis from the Nurses' Health Study.
      In contrast, dietary patterns low in processed and red meats and rich in fruits and vegetables such as the Dietary Approaches to Stop Hypertension and the Mediterranean diets have been shown to reduce CKD incidence.
      • Khatri M.
      • Moon Y.P.
      • Scarmeas N.
      • et al.
      The association between a Mediterranean-style diet and kidney function in the Northern Manhattan study cohort.
      • Huang X.
      • Jimenez-Moleon J.J.
      • Lindholm B.
      • et al.
      Mediterranean diet, kidney function, and mortality in men with CKD.
      • Rebholz C.M.
      • Crews D.C.
      • Grams M.E.
      • et al.
      DASH (Dietary Approaches to Stop Hypertension) diet and risk of subsequent kidney disease.
      • Jacobs Jr., D.R.
      • Gross M.D.
      • Steffen L.
      • et al.
      The effects of dietary patterns on urinary albumin excretion: Results of the dietary approaches to stop hypertension (DASH) trial.

      MNT

      Because CKD incidence and progression are so strongly influenced by nutrition-related factors, individualized dietary counseling or MNT should routinely be part of the care plan so that patients can make better informed choices to maximize their long-term health. Nutrition interventions have demonstrated improvements in glucose and blood pressure control, slowing of CKD progression, and delaying need for dialysis.
      National Kidney Foundation
      KDOQI clinical practice guideline for diabetes and CKD: 2012 update.
      • Klahr S.
      • Levey A.S.
      • Beck G.J.
      • et al.
      The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease study group.
      • Levey A.S.
      • Greene T.
      • Beck G.J.
      • et al.
      Dietary protein restriction and the progression of chronic renal disease: What have all of the results of the MDRD study shown? Modification of Diet in Renal Disease study group.
      • Kasiske B.L.
      • Lakatua J.D.
      • Ma J.Z.
      • Louis T.A.
      A meta-analysis of the effects of dietary protein restriction on the rate of decline in renal function.
      • Palmer S.C.
      • Maggo J.K.
      • Campbell K.L.
      • et al.
      Dietary interventions for adults with chronic kidney disease.
      • Rhee C.M.
      • Ahmadi S.F.
      • Kovesdy C.P.
      • Kalantar-Zadeh K.
      Low-protein diet for conservative management of chronic kidney disease: A systematic review and meta-analysis of controlled trials.
      • de Waal D.
      • Heaslip E.
      • Callas P.
      Medical nutrition therapy for chronic kidney disease improves biomarkers and slows time to dialysis.
      A US retrospective propensity analysis of more than 156,000 incident patients undergoing hemodialysis suggested an independent association between more than 12 months of RDN pre-hemodialysis CKD care and lower mortality during the first year of dialysis therapy.
      • Slinin Y.
      • Guo H.
      • Gilbertson D.T.
      • et al.
      Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.
      The Academy of Nutrition and Dietetics (Academy) defines MNT as “an evidence-based application of the nutrition care process.”

      Academy of Nutrition and Dietetics. Definition of terms list. Updated June 2017. http://www.eatrightpro.org/resources/practice/quality-management/scope-of-practice. Accessed January 8, 2018.

      In addition, the Academy states that MNT may include nutrition assessment/reassessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation that typically results in the prevention, delay, or management of diseases and/or conditions.

      Academy of Nutrition and Dietetics. Definition of terms list. Updated June 2017. http://www.eatrightpro.org/resources/practice/quality-management/scope-of-practice. Accessed January 8, 2018.

      Although dietary counseling may be provided to patients by primary care physicians, nephrologists, or nursing professionals, the counseling is often brief and only involves broad suggestions such as reducing salt or protein intake. In contrast, MNT includes an in-depth individualized nutrition assessment, as well as the design and application of a personalized nutrition intervention. MNT also includes periodic monitoring, evaluation, and reassessment of the interventions that are tailored to impede disease progression. Although the cost-effectiveness of MNT has not been examined in depth for CKD, MNT provided by a RDN has been shown to be cost-effective for managing diabetes and hypertension, especially among older adults, and can be cost-saving.
      • Sheils J.F.
      • Rubin R.
      • Stapleton D.C.
      The estimated costs and savings of medical nutrition therapy: The Medicare population.
      • Pastors J.G.
      • Warshaw H.
      • Daly A.
      • Franz M.
      • Kulkarni K.
      The evidence for the effectiveness of medical nutrition therapy in diabetes management.
      • Franz M.J.
      • Powers M.A.
      • Leontos C.
      • et al.
      The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults.
      • Franz M.J.
      • Splett P.L.
      • Monk A.
      • et al.
      Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus.
      • Anderson J.M.
      Achievable cost saving and cost-effective thresholds for diabetes prevention lifestyle interventions in people aged 65 years and older: A single-payer perspective.
      • Riegel G.R.
      • Ribeiro P.A.B.
      • Rodrigues M.P.
      • Zuchinali P.
      • Moreira L.B.
      Efficacy of nutritional recommendations given by registered dietitians compared to other healthcare providers in reducing arterial blood pressure: Systematic review and meta-analysis.
      Medicare coverage of MNT for management of chronic medical conditions is relatively new. The Balanced Budget Act of 1997 required the Secretary of the Department of Health and Human Services to contract with the National Academy of Sciences to examine the expected costs and benefits of covering MNT services for Medicare beneficiaries.

      Department of Health and Human Services, Centers for Medicare and Medicaid services. Medicare program; revisions to payment policies and five-year review of and adjustments to the relative value units under the physician fee schedule for calendar year 2002; final rule. https://www.gpo.gov/fdsys/pkg/FR-2001-11-01/pdf/01-27275.pdf Accessed January 14, 2018.

      In response to this request, the Institute of Medicine (IOM) published the report Role of Nutrition in Maintaining Health in the Nation’s Elderly in 2000.

      Institute of Medicine. The role of nutrition in maintaining health in the Nation’s elderly, Washington, D.C. National Academy Press. 2000.

      This IOM report recommended MNT services for individuals with undernutrition, cardiovascular disease, diabetes mellitus, kidney disease, and osteoporosis. Congress decided to allow Medicare coverage of MNT services for persons with diabetes mellitus and CKD and tasked the Department of Health and Human Services with making recommendations to extend coverage to the other three chronic conditions mentioned in the IOM report. In 2001, Section 105 of the Medicare, Medicaid and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act added MNT services as a Medicare benefit for persons with diabetes mellitus or nondialysis-dependent CKD and then required that “registered dietitians or nutrition professionals” be included as a Medicare provider group.

      Centers for Medicare and Medicaid Services. National coverage determination for medical nutrition therapy (180.1). Publication No. 100-3. 2002:June 14, 2016. https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=252&ver=1. Accessed June 4, 2018.

      Medicare contractors started paying the MNT Medicare claims January 1, 2002, for MNT services with an RDN for Medicare Part B enrollees diagnosed with diabetes, CKD, or who received a kidney transplant during the past 36 months with a physician referral.

      Centers for Medicare & Medicaid Services. Your Medicare coverage. https://www.medicare.gov/coverage/nutrition-therapy-services.html. Updated 2015. Accessed May 1, 2015.

      Most private insurers cover services as provided by Medicare and also provide MNT coverage for persons with CKD or diabetes.
      During the first year that MNT is provided, Medicare patients are eligible for 3 hours of either face-to-face counseling or counseling via an interactive telecommunications system originating from a site located in a county outside of a Metropolitan Statistical Area or a rural Health Professional Shortage Area within a rural census tract. During subsequent years, patients are eligible for 2 hours of counseling every year. The treating physician must provide a referral for MNT and indicate a diagnosis of diabetes or nondialysis-dependent CKD (CKD G stages 3, 4, or 5). Nonphysician practitioners cannot make referrals for this service. The MNT benefits covered by Medicare are considered a stand-alone billable service. Additional hours of MNT services are available to Medicare patients when the treating physician determines there is a change in diagnosis or medical condition that requires dietary changes, but the physician must write a second referral for MNT within the same calendar year.
      For patients with diabetes and CKD, DSMT may also be provided along with MNT, but practitioners cannot bill for DSMT and MNT benefits delivered on the same day. DSMT and MNT are different benefits and require separate referrals from a physician. DSMT is more general and includes basic training on diabetes self-care behaviors primarily in group formats. The goal of DSMT is to increase patient knowledge of why and how to change behaviors. In contrast, MNT provides individualized nutrition therapy to control diabetes and prevent CKD progression and personalized behavior change plans that may include eating plans, exercise, and control of stress. The Affordable Care Act expanded access to preventive services for people receiving Medicare, including MNT, by eliminating cost sharing for these preventive services. Currently, MNT requires no out-of-pocket expenses for Medicare beneficiaries who meet eligibility for MNT services and similar MNT coverage is often available via Medicaid and private payers as well.

      Underuse of MNT

      Currently, MNT is recommended by the National Kidney Foundation and the Academy for all persons with CKD regardless of stage.
      National Kidney Foundation
      KDOQI clinical practice guideline for diabetes and CKD: 2012 update.
      National Kidney Foundation
      K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification and stratification.

      Academy of Nutrition and Dietetics chronic kidney disease (CKD) evidence-based nutrition practice guideline. 2010. http://www.andeal.org/vault/pq119.pdf. Accessed January 17, 2017.

      MNT is also recommended by the American Diabetes Association for all individuals with diabetes,
      • Evert A.B.
      • Boucher J.L.
      • Cypress M.
      • et al.
      Nutrition therapy recommendations for the management of adults with diabetes.
      • Franz M.J.
      • Powers M.A.
      • Leontos C.
      • et al.
      The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults.
      • Andrews R.C.
      • Cooper A.R.
      • Montgomery A.A.
      • et al.
      Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: The early ACTID randomised controlled trial.
      the number-one cause of kidney disease in the United States. Unfortunately, the overwhelming majority of US patients with CKD are not meeting with RDNs until they develop kidney failure and start dialysis because dialysis units are mandated to provide MNT services to all patients with ESRD. Although few studies have examined MNT use, existing data suggest that only one out of 10 patients with CKD receive any MNT before initiating dialysis.
      • Slinin Y.
      • Guo H.
      • Gilbertson D.T.
      • et al.
      Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.
      In 2016, approximately 7,100 Medicare claims for new patient visits for the CKD MNT benefit were recorded in the entire United States despite the fact that almost 2.7 million Medicare beneficiaries aged 65 years and older have CKD.

      RBRVS Data Manager online. American Medical Association. https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod280002&navAction=push. 2017. Accessed June 4, 2018.

      US Renal Data System
      USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.
      Although it is likely that adults with diabetes are receiving general dietary counseling from their primary care practitioners, they are not meeting with RDNs to receive more intensive and individualized support for dietary modification. More time spent with an RDN may improve outcomes for patients with CKD.
      • Steiber A.L.
      • Leon J.B.
      • Hand R.K.
      • et al.
      Using a web-based nutrition algorithm in hemodialysis patients.
      Among adults with type 2 diabetes, the number of visits and time spent with RDNs correlate with improvements in glucose and blood pressure control.
      • Lemon C.C.
      • Lacey K.
      • Lohse B.
      • Hubacher D.O.
      • Klawitter B.
      • Palta M.
      Outcomes monitoring of health, behavior, and quality of life after nutrition intervention in adults with type 2 diabetes.

      Issues of Billing

      The low use of MNT services for persons with CKD may in part be a function of the existing reimbursement rates and billing implementation challenges for these services. National payment rates by Medicare for MNT services for patients with nondialysis-dependent CKD range from $132 to $141/hour for an initial visit and $112 to $122/hour for follow-up visits. Group sessions, which may include 2 or more patients, are paid at $31 to $32/hour per patient.

      Centers for Medicare and Medicaid Services. Physician fee schedule CY18. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Accessed March 20, 2018.

      Figure 1 shows the Current Procedural Terminology codes used to bill Medicare Part B for MNT services and Figure 2 shows the requirements for reimbursement. To bill Medicare Part B, MNT services must be provided by an RDN enrolled in the Medicare program. In the case that such services are billed through a physician office practice or hospital outpatient clinic, an RDN must reassign his/her benefits to the practice/clinic. Some health centers and practice settings may opt to simply not provide MNT because of low reimbursement for these services.
      Figure 1Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology
      CPT Copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
      (CPT) codes for Medical Nutrition Therapy (MNT). All assessments must be face to face.
      HCPCS/CPT codeMNT code descriptor
      97802MNT; initial assessment and intervention, individual, face to face with the patient, each 15 min
      97803MNT; reassessment and intervention, individual, face to face with the patient, each 15 min
      97804MNT; group (2 or more individual(s)), each 30 min
      G0270MNT reassessment and subsequent intervention(s) for change in diagnosis, individual, each 15 min
      G0271MNT reassessment and subsequent intervention(s) for change in diagnosis, group (2 or more), each 30 min
      a CPT Copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
      Figure 2Provider and patient qualifications for Medicare billing for medical nutrition therapy.
      Provider qualificationPatient qualification
      Registered dietitian nutritionistType 1 or type 2 diabetes, or estimated glomerular filtration rate 13-50 mL/min and no use of dialysis or kidney transplantation within past 36 mo
      Medicare provider statusCannot be inpatient stay in hospital or skilled nursing facility
      Use of nationally recognized protocolsInternational Classification of Diseases version 10 codes indicating medical necessity
      Hospital outpatient department or independent practice settingChange in diagnosis requiring dietary changes may be used to extend medical nutrition therapy services
      Another barrier for implementing MNT services is a current workforce gap in RDNs credentialed with Centers for Medicare and Medicaid Services to provide and bill for MNT. In a survey conducted by the Academy in 2013 on coding and billing practices of RDNs, only about half of RDNs (48.2%) providing MNT services in an ambulatory care setting indicated they were Medicare providers.
      • Parrott J.S.
      • White J.V.
      • Schofield M.
      • Hand R.K.
      • Gregoire M.B.
      • Ayoob K.T.
      • Pavlinac J.
      • Lewis J.L.
      • Smith K.
      Current coding practices and patterns of code use of registered dietitian nutritionists: The Academy of Nutrition and Dietetics 2013 coding survey.
      The most common reasons cited for not being a Medicare provider included “employer says don’t need to become a Medicare provider,” “do not provide MNT to Medicare eligible patients,” “don’t know how to become a Medicare provider,” and “provide MNT to Medicare patients for diagnoses not covered by Medicare.”
      • Parrott J.S.
      • White J.V.
      • Schofield M.
      • Hand R.K.
      • Gregoire M.B.
      • Ayoob K.T.
      • Pavlinac J.
      • Lewis J.L.
      • Smith K.
      Current coding practices and patterns of code use of registered dietitian nutritionists: The Academy of Nutrition and Dietetics 2013 coding survey.
      In addition, 16% stated low reimbursement as a reason for not billing for MNT services.
      • Parrott J.S.
      • White J.V.
      • Schofield M.
      • Hand R.K.
      • Gregoire M.B.
      • Ayoob K.T.
      • Pavlinac J.
      • Lewis J.L.
      • Smith K.
      Current coding practices and patterns of code use of registered dietitian nutritionists: The Academy of Nutrition and Dietetics 2013 coding survey.

      Medicaid

      Medicaid is a state-administered program and benefits and payment are determined at the state level. Coverage for MNT services provided by RDNs varies widely across the country and providers should check with their state Medicaid program to determine MNT eligibility. Although federal guidelines do not require state Medicaid programs to provide coverage for patients with nondialysis-dependent CKD in alignment with Medicare Part B coverage, many states choose to do so. However, some state Medicaid programs do not recognize RDNs as independent providers, or limit such status to specific sites of service (eg, hospital outpatient clinics). In these situations, MNT services provided by RDNs must be billed incident to a physician (ie, using the physician’s National Provider Identifier [NPI]). Thus MNT services cannot be provided on the same day as a physician office visit because Medicaid will not pay for two visits for the same provider on the same day. Regarding rural health clinics, their unique design of payment structures prohibits billing for Medicare for MNT services furnished by an RDN, although such services may be considered incident to a visit with a rural health clinic practitioner.

      Physician Barriers

      The low MNT use by patients with CKD may also be attributed in part to lack of physician referral, although this has not been well documented. Some physicians may be operating under an old and incorrect assumption that payment for MNT services does not exist. Practitioner factors identified as barriers to use of preventive services in general include bias, cultural competence, communication barriers, and ability to ensure shared decision making.
      • Strawbridge L.M.
      • Lloyd J.T.
      • Meadow A.
      • Riley G.F.
      • Howell B.L.
      Use of Medicare's diabetes self-management training benefit.
      In addition, physicians may not recognize the strong role that dietary factors have on CKD progression and how MNT may improve disease management.
      • Stenvinkel P.
      • Ikizler T.A.
      • Mallamaci F.
      • Zoccali C.
      Obesity and nephrology: Results of a knowledge and practice pattern survey.
      Even in the case that physicians do recognize the role of dietary practices in CKD management, MNT services are not being prescribed to alter dietary behavior. This clinical inertia may be rooted in pessimistic views about patients’ ability to change their lifestyle and lack of confidence in outside treatment.
      • Steeves J.A.
      • Liu B.
      • Willis G.
      • Lee R.
      • Smith A.W.
      Physicians' personal beliefs about weight-related care and their associations with care delivery: The U.S. National Survey of Energy Balance Related Care among Primary Care Physicians.
      • Smith A.W.
      • Borowski L.A.
      • Liu B.
      • et al.
      U.S. primary care physicians’ diet-, physical activity-, and weight-related care of adult patients.
      • Ferrante J.M.
      • Piasecki A.K.
      • Ohman-Strickland P.A.
      • Crabtree B.F.
      Family physicians’ practices and attitudes regarding care of extremely obese patients.
      • Epling J.W.
      • Morley C.P.
      • Ploutz-Snyder R.
      Family physician attitudes in managing obesity: A cross-sectional survey study.
      In addition, ancillary services for physicians have been reduced substantially in most health care systems, limiting the amount of time directly spent with patients while increasing time spent on administrative duties and clinical electronic documentation. Although no studies have examined this issue specifically for physicians caring for patients with CKD, the lack of billable time necessary to coordinate preventive services for patients likely remains an additional barrier for MNT referral.
      In 2013, the Academy Renal Dietetic Practice Group surveyed its members regarding the provision of the Medicare Part B benefit to patients with nondialysis-dependent CKD. Only 43.9% of renal RDNs indicated they receive physician referrals for their MNT services.
      • Kent P.S.
      • McCarthy M.P.
      • Burrowes J.D.
      • et al.
      Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nephrology nutrition.
      Figure 3 shows the respondents perceived barriers to physician referrals to RDNs. The most common perceived reason for lack of physician referral for MNT services was perceived cost to patients despite the fact that MNT services are often available to patients with no copay. There are also anecdotal reports that physicians have difficulty locating an RDN. Fundamentally, this is an issue of RDNs often not being recognized as an integral member of the medical team. Difficulties in locating a RDN may also be due to provider shortages in some geographic markets. Nephrologists and primary care practitioners often have experience working in team-based inpatient care that includes RDNs, and nephrologists routinely collaborate with RDNs in dialysis clinic settings. However, outpatient CKD MNT RDN interactions are infrequent as previously noted. Specific MNT interventions may be of interest, but experience in prescribing nondialysis CKD MNT and knowledge about individualized dietary plan elements is suboptimal among nephrologists.
      • Kalantar-Zadeh K.
      • Moore L.W.
      • Tortorici A.R.
      • et al.
      North American experience with low protein diet for non-dialysis-dependent chronic kidney disease.
      Lastly, current clinical practice guidelines in nephrology do not emphasize the role of RDNs in nondialysis CKD. The international Kidney Disease Improving Global Outcomes group has not published any dedicated nutrition guideline. In the United States, the Kidney Disease Outcomes Quality Initiative Nutrition guideline published in 2000 included a scope limited to dialysis-treated patients.
      Clinical practice guidelines for nutrition in chronic renal failure
      K/DOQI, National Kidney Foundation.
      A CKD nutrition guideline is currently being developed via collaboration between the Academy and the Kidney Disease Outcomes Quality Initiative and will help fill this existing void for patients with nondialysis CKD.
      Figure 3Perceived barriers for lack of physician referral for medical nutrition therapy services reported by registered dietitian nutritionists (RDNs). Data from Kent and colleagues.
      • Kent P.S.
      • McCarthy M.P.
      • Burrowes J.D.
      • et al.
      Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nephrology nutrition.
      Stated reason% Reported
      Cost to patient; out-of-pocket costs not covered by insurance73
      Physician chooses to counsel patient on nutrition53
      Physician lack of time to refer/does not think about referring to RDNs54
      Lack of physician awareness of available nutrition services58
      Lack of patient interest in being referred to another professional46
      Lack of knowledge on how to locate an RDN with expertise in CKD management and/or eligibility requirements and billing codes for MNT services may also impede physician referral. Physicians should be aware that existing nutrition handouts and available handheld device applications to assist with diet may be helpful as supporting tools for some patients, but are neither a substitute for MNT nor sufficient to help most individuals make lifestyle changes to address chronic diseases, including CKD. MNT delivered by an RDN is most likely to provide an individualized approach to patients that considers CKD stage, comorbidities, CKD complications such as hyperkalemia and hyperphosphatemia, and unique dietary concerns as well as preferences in the design and implementation of an individualized dietary plan.

      Patient Barriers

      Patient perceived barriers for use of preventive services in general include cost and time burden for scheduling and completing the services. Patient characteristics such as health literacy and functional limitations may also impede use of preventive services.
      • Strawbridge L.M.
      • Lloyd J.T.
      • Meadow A.
      • Riley G.F.
      • Howell B.L.
      Use of Medicare's diabetes self-management training benefit.
      • Green C.A.
      • Johnson K.M.
      • Yarborough B.J.
      Seeking, delaying, and avoiding routine health care services: Patient perspectives.

      The Henry J. Kaiser Foundation. Preventive services covered by private health plans under the Affordable Care Act. https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/. Accessed January 14, 2018.

      RDNs are not routinely available in physician-based clinics, which makes transportation a major barrier for some patients to receive dietary counseling. Alternate places for dietary counseling such as the supermarket or retail stores have been suggested.
      • Galasso P.
      • Amend A.
      • Melkus G.D.
      • Nelson G.T.
      Barriers to medical nutrition therapy in black women with type 2 diabetes mellitus.
      Telephone or video counseling services are not covered under Medicare unless the patient resides in a rural area. According to data obtained from a recent focus group which included 21 patients with nondialysis-dependent CKD and three caregivers, telenutrition via video conferencing may increase access to MNT.

      Kelly JT, Campbell KL, Hoffmann T, Reidlinger DP. Patient experiences of dietary management in chronic kidney disease: A focus group study [published online ahead of print November 14, 2017]. J Ren Nutr. https://doi.org/10.1053/j.jrn.2017.07.008.

      For Medicare to cover telehealth services under Medicare Part B, an interactive two-way telecommunication system with real-time audio and video must be used and the patient must be located at a doctor’s office, hospital, or health clinic; patients cannot be at their home or work when engaging in telenutrition services. Telenutrition services have been successfully used for diabetes,
      • Izquierdo R.E.
      • Knudson P.E.
      • Meyer S.
      • Kearns J.
      • Ploutz-Snyder R.
      • Weinstock R.S.
      A comparison of diabetes education administered through telemedicine versus in person.
      weight management,
      • Rollo M.E.
      • Hutchesson M.J.
      • Burrows T.L.
      • et al.
      Video consultations and virtual nutrition care for weight management.
      • Castelnuovo G.
      • Manzoni G.M.
      • Cuzziol P.
      • et al.
      TECNOB study: Ad interim results of a randomized controlled trial of a multidisciplinary telecare intervention for obese patients with type-2 diabetes.
      • Ahrendt A.D.
      • Kattelmann K.K.
      • Rector T.S.
      • Maddox D.A.
      The effectiveness of telemedicine for weight management in the MOVE! program.
      and for improving nutrition for adults living in rural areas
      • Johnson A.
      • Gorman M.
      • Lewis C.
      • Baker F.
      • Coulehan N.
      • Rader J.
      Interactive videoconferencing improves nutrition intervention in a rural population.
      and the elderly.
      • Guilfoyle C.
      • Wootton R.
      • Hassall S.
      • Offer J.
      • Warren M.
      • Smith D.
      Preliminary experience of allied health assessments delivered face to face and by videoconference to a residential facility for elderly people.
      Telenutrition services have also shown effectiveness for overall chronic disease management.
      • Kelly J.T.
      • Reidlinger D.P.
      • Hoffmann T.C.
      • Campbell K.L.
      Telehealth methods to deliver dietary interventions in adults with chronic disease: A systematic review and meta-analysis.
      However, studies have not examined the effectiveness of telenutrition services for slowing CKD progression.

      Potential Solutions

      Examples of novel ways to incorporate MNT into practice include the Comprehensive Primary Care Initiative (CPCI) and CPCI+.

      Comprehensive primary care plus. https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus. Updated 2018. Accessed February 8, 2018.

      The CPCI is a pilot program conducted by the Centers for Medicare and Medicaid Services Innovation Center via the Affordable Care Act that aims to foster collaboration between public and private payers to strengthen primary care and offset nonbillable provider time necessary to coordinate primary care for patients. Medicare and some commercial and state health insurance plans offer bonus payments to primary care practices that participate in CPCI but this program is only available in a few states. CPCI+, with almost 3,000 clinics in 18 regions now participating, is a public-private partnership with two primary care practice tracks that incrementally advances care delivery requirements and payment options.

      Comprehensive primary care plus. https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus. Updated 2018. Accessed February 8, 2018.

      The goals of this program along with its payment design offers opportunities to integrate RDNs into the care team and provide a different payment stream for MNT services for patients with CKD (and other nutrition-related health conditions).
      Another alternative to increasing MNT use is by incorporating RDNs into a CKD management team. These health care teams may become more common as health care payments shift from volume-based to value-based payments. To provide the framework for achieving changes in payment structure, the Department of Health and Human Services classified payment models into four payment model categories. As you move from a category one to a category four payment model, payments evolve from strictly fee-for-service to more value-based population management payment based models.

      3M health information systems. Hierarchical condition categories (HCCs) and the shift to value based reimbursement. Report no. 70-2011-6664-5. http://multimedia.3m.com/mws/media/1340264O/hccs-and-shift-to-value-based-reimbursement-white-paper.pdf. Accessed January 13, 2018.

      The shift from fee-for-service to value-based payment models offers opportunities to structure new and financially viable models for MNT services. One example is leveraging the per-member per-month payment model to integrate the RDN into the person-centered primary care team. The results from this payment model have been very positive, particularly for high-risk patients.
      • Wang Q.C.
      • Chawla R.
      • Colombo C.M.
      • Snyder R.L.
      • Nigam S.
      Patient-centered medical home impact on health plan members with diabetes.
      In addition, bundled payments, shared savings, and quality incentive programs offer other nonfee-for-service methods for covering nutrition services as the RDN contributes to improved outcomes and lower costs of care.
      • Jortberg B.T.
      • Fleming M.O.
      Registered dietitian nutritionists bring value to emerging health care delivery models.
      For example, the Academy modeled the financial viability of including RDNs in federally qualified health centers and determined a 1.16 return on investment using conservative estimates. Potential payment streams included fee-for-service, per-member per-month payments; quality incentive payments; shared savings; Special Supplemental Nutrition Program for Women, Infants, and Children and Ryan White funding; early and periodic screening, diagnostic, and treatment service payments; maternal and child health services; and grant funding. In September 2017, the National Kidney Foundation introduced legislation (HR 3867) to create a care management CKD demonstration project that covers the spectrum of care from primary care to nephrology services, including MNT, as part of the expected care, indirectly incentivizing MNT referral.

      H.R.3867-to amend title XVIII of the Social Security act to create care management demonstration programs for chronic kidney disease under the Medicare program, and for other purposes. 115th congress (2017-2018). https://www.congress.gov/bill/115th-congress/house-bill/3867. Updated 2018. Accessed March 6 2018.

      The existing barriers to MNT services noted above are not insurmountable, as evidenced by creative solutions implemented by physicians and RDNs across the United States, practicing in a variety of settings. Although having an RDN onsite in a physician office practice, either through an employment or contractual arrangement, provides many benefits, this arrangement may not be practical in certain situations. A physician practice can develop a collaborative relationship with an RDN practice in its community. For example, via a Childhood Obesity Performance Improvement collaborative run by the American Academy of Pediatrics, the Academy, and the Alliance for a Healthier Generation, pediatric offices were matched with RDNs and a variety of partnership models were tested. These models included full- or part-time RDNs employed by pediatric offices to provide MNT services within the medical practice, referral to community-based RDNs (hospital outpatient clinic or RDN private practice), community-based RDNs onsite in medical practices during specific hours with warm hand-off from the pediatrician, and first visit with community-based RDNs at pediatric offices with subsequent visits at an RDN’s office. Results indicated that all models could be viable options and should be selected based on the specific situation.
      Another option is using shared medical appointments as a means to provide RDN services onsite to achieve quality outcomes in a cost-effective manner. States such as Vermont
      • Bielaszka-DuVernay C.
      Vermont's blueprint for medical homes, community health teams, and better health at lower cost.
      and North Carolina

      Dubard A. Savings impact of community care of North Carolina: A review of the evidence. https://www.communitycarenc.org/media/files/data-brief-11-savings-impact-ccnc.pdf. Accessed January 14, 2018.

      are utilizing community health teams that incorporate RDNs to bring MNT services to primary care practices for patients with chronic diseases. These teams essentially provide a set of shared resources to practices that cannot afford to employ the full team of health care providers necessary to meet the needs of the populations served.

      Conclusions

      CKD is an important public health problem and increasing use of MNT should improve risk factor control of diabetes
      • Pastors J.G.
      • Warshaw H.
      • Daly A.
      • Franz M.
      • Kulkarni K.
      The evidence for the effectiveness of medical nutrition therapy in diabetes management.
      • Franz M.J.
      • Splett P.L.
      • Monk A.
      • et al.
      Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus.
      • Anderson J.M.
      Achievable cost saving and cost-effective thresholds for diabetes prevention lifestyle interventions in people aged 65 years and older: A single-payer perspective.
      • Franz M.J.
      • Powers M.A.
      • Leontos C.
      • et al.
      The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults.
      and hypertension,
      • Riegel G.R.
      • Ribeiro P.A.B.
      • Rodrigues M.P.
      • Zuchinali P.
      • Moreira L.B.
      Efficacy of nutritional recommendations given by registered dietitians compared to other healthcare providers in reducing arterial blood pressure: Systematic review and meta-analysis.
      slow CKD progression,
      • de Waal D.
      • Heaslip E.
      • Callas P.
      Medical nutrition therapy for chronic kidney disease improves biomarkers and slows time to dialysis.
      and reduce health care costs.
      • Sheils J.F.
      • Rubin R.
      • Stapleton D.C.
      The estimated costs and savings of medical nutrition therapy: The Medicare population.
      Unfortunately, few patients with CKD are receiving any MNT services until they initiate dialysis. Multiple barriers exist for implementation of MNT services, including low reimbursement rates, physician and patient time limitations, and patients’ access to care. Only a limited number of RDNs are trained in CKD management and many are not enrolled as Medicare providers and this workforce gap must be addressed. More research is also needed to study the barriers to MNT use and effective solutions and optimal methods for implementing MNT into routine clinical practice. The high burden, cost, and growth of CKD requires urgent action and MNT services must be a part of any broad plan to reduce ESRD incidence and improve public health.

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      Biography

      H. Kramer is an associate professor, Department of Public Health Sciences and Medicine, Division of Nephrology and Hypertension, Loyola University of Chicago, Maywood, IL.
      E. Y. Jimenez is a research associate professor, Departments of Pediatrics and Internal Medicine, University of New Mexico Health Science Center, Albuquerque, and director of the Nutrition Research Network, Academy of Nutrition and Dietetics, Chicago, IL.
      D. Brommage is senior scientific director, National Kidney Foundation, New York, NY.
      E. Montgomery is senior project director, Primary Care Initiative, National Kidney Foundation, New York, NY.
      J. Vassalotti is chief medical officer, National Kidney Foundation, and associate clinical professor, Department of Medicine - Renal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
      A. Steiber is chief science officer, Academy of Nutrition and Dietetics, Chicago, IL.
      M. Schofield is senior director of governance for nutrition services coverage, Academy of Nutrition and Dietetics, Chicago, IL.