New York Times News Service
By ROBERT PEAR
WASHINGTON, Dec. 31 — Starting on Tuesday (January 1, 2002),
Medicare will recognize and pay for two services badly needed
but little used by the elderly, nutrition therapy and pain
The nutrition benefits will be available to more than seven
million people who have diabetes or kidney disease, helping
them choose the kinds of foods that can control or treat their
illnesses. Based on the experiences of this group, the
secretary of health and human services is supposed to advise
Congress whether similar benefits should be made available to
other people on Medicare, providing ways to reduce high blood
pressure or to lower cholesterol, for example.
Cindy Moore, director of nutrition therapy at the Cleveland
Clinic Foundation and a spokeswoman for the American Dietetic
Association, said: "There is enormous potential for
medical nutrition therapy to save taxpayers dollars and
improve the quality of life for patients. Diet has a major
role in the management of diabetes and can help reduce the
risk of getting many other chronic diseases of aging like
heart disease, osteoporosis and cancer."
Doctors said Medicare's decision to recognize pain
management as a specialty would help many patients with
cancer, sickle cell disease and other conditions that cause
Medicare's coverage decisions often influence private
insurers. Dietitians and doctors who specialize in pain
medicine said they hoped private insurers would follow the
example set by Medicare in recognizing the value of their
For years, dietitians have sought Medicare coverage of
nutrition counseling and therapy. Congress, as part of a law
passed in December 2000, agreed to provide the benefits after
receiving a report from the National Academy of Sciences that
said such coverage was likely to save money for Medicare and
Nutrition therapy is supposed to mesh with other types of
care that a patient receives. The patient must have a referral
from a treating physician — the primary care doctor or
specialist coordinating the patient's care. The government
will then pay for a registered dietitian or other nutrition
professional to assess the patient's needs, provide counseling
and develop a treatment plan to improve the patient's diet.
The Department of Health and Human Services estimates that
Medicare will spend $270 million on nutrition therapy benefits
in the first five years. It has not estimated the savings that
might result from a reduction in hospital admissions, surgery
and other costs.
Ms. Moore said a dietitian might charge $100 to $130 for 45
minutes to an hour of counseling. A visit to a doctor could
cost three to five times as much, and a surgical procedure
would cost far more.
In recent years, Medicare has slowly expanded to encompass
a small but growing number of preventive health care services.
Nutrition therapy illustrates that trend.
On Tuesday, the government will also establish a
reimbursement code allowing doctors to identify themselves as
specialists in pain management. This is a major accomplishment
for the field of pain medicine and will make it easier for
doctors to bill Medicare for these services.
Kimberly A. Kutska, a spokeswoman for the American Academy
of Pain Medicine, said the new billing code would help
patients and doctors.
"Often," Ms. Kutska said, "specialists in
pain medicine don't get properly reimbursed for the procedures
because they don't have their own specialty code."
Many expert studies have concluded that patients are not
being adequately treated for chronic pain. The Medicare
reimbursement code will encourage doctors to provide such
treatment to patients with cancer, arthritis, sickle cell
anemia, AIDS and other diseases that cause severe pain.
Dr. Albert L. Ray, president of the American Academy of
Pain Medicine, said, "With the new code, it will be far
easier for patients to identify and locate doctors who
specialize in pain medicine."
Such doctors may now be listed as neurologists,
neurosurgeons, anesthesiologists, psychiatrists or specialists
in rehabilitation medicine.
Medicare provides health insurance for 40 million people
who are elderly or disabled. About 6.3 million people ages 65
or older — more than 18 percent of the elderly — have
diabetes and could qualify for nutrition therapy, according to
In addition, Josef Coresh, an epidemiologist at Johns
Hopkins University, said that eight million people had lost at
least half of their kidney function and that six million of
them were 65 or older. Those with advanced kidney disease may
have priority in receiving nutrition therapy. About 330,000
elderly people have lost at least three-fourths of their
kidney function and are likely to have the most severe
nutritional deficiencies, Dr. Coresh said.
"People with kidney disease become nauseous, lose
their appetite, have a higher risk of malnutrition and have
poorer metabolism of the food they do eat," he said.
"So they should be able to benefit from nutrition
Another change in Medicare that takes effect on Tuesday
will limit the ability of beneficiaries to move into and out
of health maintenance organizations. They have been able to
drop out of H.M.O.'s or switch to other health plans once a
month. But in the coming year, they will be able to make only
one change, in the first six months of the year. In the annual
open enrollment period in November, they will be able to make
a new choice for 2003.
Organizations representing Medicare beneficiaries and
H.M.O.'s have lobbied Congress to repeal the law that locks
patients into health plans, but Congress has not taken action.
A new paradigm is emerging in health care. Soon we will
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Soon we will spend most of our health care dollars BEFORE we
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