Diana, why doesn't my cancer center have a Registered Dietitian (RD) on staff to provide nutritional education as part of my comprehensive cancer care? Is there anything I can do to change this situation?
Since I began this web site in 1998, your first question has been the most common one I have received, from both patients and professional members of the oncology health care community.
The answer to your first question is complex and multi-focused in nature, revolving around various concerns such as:
On a positive note, some cancer treatment facilities (Comprehensive Cancer Centers , Community Cancer Centers , and oncologists in private practice) have hired RDs to be part of their staff during the past 10 years. These centers are to be commended. This does not mean they are staffed adequately yet, but they are leading the way toward providing true comprehensive cancer care!
All of these centers (including those that have not yet hired an RD) have struggled with determining what level of nutrition screening, assessment, education, and monitoring should be available to patients from RDs due to the underlying concern surrounding the additional costs involved to provide these professional services and the current lack of insurance reimbursement of these services from Medicare and/or private insurers.
Research is showing that nutrition intervention does improve treatment tolerance and quality of life (these are called outcome studies). In addition, some early research is emerging to show that nutrition intervention can enhance the potential for long-term survival. Finally, what will also be needed is the demonstration that medical nutrition therapy by RDs can also save overall health care costs by producing beneficial and cost saving outcomes for cancer patients such as:
to name just a few ways that medical nutrition therapy by RDs can potentially be beneficial for cancer patients.
To answer the second part of your question, first of all, I suggest that you contact the medical director and/or administrator of your local cancer treatment facility and express your desire to have nutritional therapy delivered proactively and in an individualized manner by an RD knowledgeable about oncology nutrition as part of standard practice for comprehensive cancer care. I have seen situations where having many patients express that need has helped the medical director and administrator figure out some creative way to hire an RD as part of the cancer center's staff, even without insurance companies reimbursing the cost of the professional service. Remember two points here: 1) You, the patient, are also the customer and, and 2) the simple “squeaky wheel” phenomenon, i.e., what the customer asks for, the customer often receives.
In addition, here is what is new in 2005 and another way that you can help!
New legislation called The Medicare Medical Nutrition Therapy Act of 2005 has recently been introduced into the 109 th Congress in both the Senate (S604) and the House of Representatives (HR1582). Each side of the bill already has several co-sponsors and bipartisan support.
The text of the short identical versions of the bill can be read at the following web sites:
In a nutshell, this bill would give the Centers for Medicare and Medicaid Services (CMS) the authority to cover the cost of providing Medical Nutrition Therapy (MNT) by Registered Dietitians (RD) beyond the current legislated coverage of diabetes and kidney failure when scientific evidence shows it would be both beneficial and cost effective in treating ambulatory patients (i.e., people needing nutritional care as outpatients, not while hospitalized) with other serious diseases or conditions. This is a cost neutral expansion that would likely result in the coverage of MNT for cancer along with other diseases such as dyslipidemia, hypertension, HIV/AIDS, obesity, metabolic syndrome, pre-diabetes, and pre-hypertension. (Historically, when Medicare begins coverage of a procedure or professional service, private insurance companies soon offer equivalent coverage.)
Please send a letter to your senators and representatives now urging them to support this important legislation. Please also send a letter of thanks if one of your senators or representative has already demonstrated his/her support for this important legislation.
To find your congressional representative's name and his/her web site, go to www.house.gov
To find your senators' names and web sites, go to www.senate.gov
To find out if your senator or representative has already signed on as a co-sponsor of these bills, go to http://thomas.loc.gov/; enter the bill number in the search function (S604 or HR 1582). Then click on the Bill Summary & Status link. As of April 21, 2005 , 15 senators are co-sponsoring the bill and 17 representatives.
It is recommended that you contact your Representatives and Senators by Email (or fax), which is available on their web sites. For the Email subject line, put in "HR1582" to House members or "S.604" for Senators. (I have included a sample letter below.)
Unfortunately, I have heard that this bill is unlikely to pass as a stand-alone bill this year, but it has potential to be tacked onto another bill as an amendment. Thus, it is very important to contact your two senators and one representative now to let them know their support is crucial to obtain passage of this bill this year.
Both the American Dietetic Association and the Oncology Nutrition Dietetic Practice Group of the ADA support this legislation and are actively working to increase its chances of passing so that Medical Nutritional Therapy can be provided to all those people with a cancer diagnosis along with other appropriate medical conditions.
In order to fully obtain reimbursement of the professional services of a Registered Dietitian for Medical Nutritional Therapy for cancer patients, benefits and overall cost reduction of health care expenditures will still need to be demonstrated. So there is still a great deal of research needed. However, some is in place, some is in progress, and it is hopeful that if this legislation is passed, nutritional care will ultimately become part of true comprehensive cancer care at cancer treatment facilities everywhere.
Nutritional care for people with a cancer diagnosis is too important to be left to advice from a clerk at a local health food store or even to the generalized information that my web site can provide at this critical time. In order for cancer therapy to be truly comprehensive, Registered Dietitians with experience and expertise in oncology nutrition should provide Medical Nutrition Therapy to all people struggling to recover from cancer.
There are over 1.2 million new cases of cancer diagnosed annually in the US , with nearly 10 million people currently alive after a cancer diagnosis. Nearly all cancer patients would benefit from MNT by RDs to optimize treatment outcome and quality of life, first during treatments themselves and then to achieve the best health possible after completion of treatment.
Ultimately, passage of The Medicare Medical Nutrition Therapy Act of 2005 will permit the inclusion of individualized, pro-active and in-depth Medical Nutritional Therapy provided by a Registered Dietitian as a covered and reimbursable professional service for people with cancer. Cancer treatment facilities will be staffed appropriately to permit appropriate nutritional screening, assessments, intervention, education, and monitoring for all patients, including those who have been newly diagnosed, are now undergoing active treatments, those finished therapy and now working toward full recovery, in addition to those for whom hospice and palliative care is the appropriate goal.
I'm sure that you have previously read one of my favorite quotations:
doubt that a small, group of thoughtful, committed citizens can
change the world. Indeed, it is the only thing that ever has.”
Thank you for asking your very good question. I hope you will write your legislators in Washington , DC and also be part of the solution to this problem that prompted your concern!
SAMPLE LETTER FOR SUPPORT OF THE MEDICARE MEDICAL NUTRITION THERAPY ACT OF 2005 (S604 AND HR1582)
Subject: S604 or HR1582, Medicare Medical Nutrition Therapy Act of 2005
Dear Senator (or Representative) _______________:
I would like to ask for your co-sponsorship of S604, the "Medicare Medical Nutrition Therapy Act of 2005" introduced by Larry Craig of Idaho (or HR1582 introduced by Rep. Fred Upton of Michigan ). (Be sure to say, “Thanks” if they have already signed on as a sponsor!)
This important cost-neutral legislation gives the Secretary of Health and Human Services, acting through the Centers for Medicare and Medicaid Services, the authority to use the National Coverage Determination Process to expand coverage of Medical Nutrition Therapy (MNT) beyond diabetes and renal failure to other diseases and conditions such as cancer when scientific evidence shows these services would be both beneficial and cost-effective.
There are now over 1.2 million new cases of cancer diagnosed annually in the US , with an additional ~10 million people currently alive after a cancer diagnosis. The vast majority of cancer patients are already seeking nutritional information and would receive benefit from pro-active, individualized, and reliable MNT to optimize cancer treatment outcome and quality of life during treatment itself and then also to achieve the best health possible after completion of cancer treatment.
Research studies are showing benefits to cancer patients from MNT by Registered Dietitians (RDs), such as demonstrating improving tolerance to chemotherapy or radiation therapy, minimizing weight loss, maintenance of lean body mass, maintenance of or improved performance status and other quality of life parameters of vital importance to cancer patients.
Currently, nutrition services (MNT) provided by an RD are not routinely included as a component of comprehensive cancer care because these professional services are not a reimbursable expense for the cancer center. Oncologists and nurses often valiantly try to fill this gap, but not only do they not have extensive training in oncology nutrition, they really do not have the time during their busy days to also be providing this additional specialized aspect of cancer care. Thus patients often receive incomplete nutritional care, go without this vital care, or seek out nutritional information of questionable reliability from sources outside their cancer treatment facilities. Lastly, if doctors do seek reimbursement for time spent providing MNT, the reimbursable rate would be higher than that for an RD.
(Here is a good place to add an example from your own experience about how nutritional advice from a Registered Dietitian in your cancer center helped you or would have helped you with your treatments and/or recovery.)
I have focused on MNT for cancer patients in this letter because I am both a cancer survivor and a Registered Dietitian. I know how beneficial access to MNT delivered in my own cancer center by an RD with expertise in oncology nutrition would have been to me, as I did not have expertise in this complex area of practice at that time.
In addition, the Medicare Medical Nutrition Therapy Act of 2005 will help deliver beneficial and cost effective nutrition information to people with a wide variety of diseases (or conditions such as pre-diabetes and pre-hypertension).
(Here is a place to add how advice from an RD would help you, or has already helped you, with another aspect of your health such as weight control, diabetes, cardiovascular disease, hypertension, osteoporosis, etc, etc.)
The Medicare Medical Nutrition Therapy Act of 2005 is sound health care policy and fiscally responsible . It can prevent unnecessary pain and suffering and save millions of dollars in health care costs by lessening the risk of chronic disease, slowing disease progression, and reducing symptoms.
Thank you for your thoughtful consideration of the Medical Nutrition Therapy Act of 2005. I ask that you agree to be one of the cosponsors of this legislation and help bring it into law during this congressional session. If I can provide you with any additional information about this bill, or any other aspect of nutrition legislation, please feel free to contact me at 734-996-9260.
Dyer, MS, RD
faq posted 8/03, updated 10/03, 1/04, 5/05, 4/06
These questions and answers are intended to be of a general informative nature. Please consult with the Registered Dietitian in your cancer center or your health care provider for nutritional advice that can be individualized to your specific medical condition.
P.O. Box 130221, Ann Arbor, MI 48113