En español | Louis Rocco has lived with diabetes for decades, but until he met with a registered dietitian this summer, he didn't know eating too much bread was dangerous for him.
"I'm Italian, and I always eat a lot of bread,” he says. After two hour-long visits with the dietitian — including a session at his local grocery store in Philadelphia — Rocco, 90, has noticed a difference in his health.
"It's helped bring down my sugar readings,” he says of the changes in his diet, including eating less bread. “I wish I knew I could have had this help years ago."
After getting a referral from his doctor, Rocco learned that Medicare also covers personal nutritional counseling for people with diabetes or kidney disease.
The estimated 15 million Medicare enrollees with diabetes or chronic kidney disease are eligible for the benefit, but the federal health insurance program for people 65 and older and people with disabilities paid for only about 100,000 recipients to get the counseling in 2017, the latest year billing data is available. The data does not include the 20 million people enrolled in private Medicare Advantage plans.
Medicare pays for three hours of dietary counseling during the first year the benefit is used and two hours in subsequent years. A doctor can appeal to Medicare for additional nutritional therapy if the physician believes it is medically necessary.
Congress approved the benefit, which began in 2002, after studies found such counseling leads to improved health outcomes and fewer complications for older patients. Under the Affordable Care Act (ACA), the counseling has been available without out-of-pocket costs to Medicare beneficiaries since 2011.
Health experts say the little-used benefit represents a lost opportunity for beneficiaries to improve their health — and for Medicare to save money by preventing costly complications from the diseases.
An estimated 1 in 4 people aged 65 and older have diabetes and 1 in 3 have chronic kidney disease. Kidney disease is often a complication of diabetes.
Nationwide, there are 100,000 registered dietitians — more than enough to meet demand, says Krista Yoder Latortue, executive director of Family Food in Philadelphia, which employs about 50 dietitians, including the one who visited Rocco.
The problem may be either that not enough physicians know about the Medicare benefit or that those who do don't refer their patients to a dietitian, a requirement of the program. “It's easier to prescribe a medication than it is to discuss the importance of nutrition and get patients to meet with a registered dietitian,” says Holly Kramer, a Chicago nephrologist and president of the National Kidney Foundation.
"I don't understand how we have this burgeoning obesity and diabetes epidemic and we are not using dietitians in our clinics for all these patients, yet we are paying for all these things that mediate from the disease process such as arthritis, dialysis and amputations,” she says. “It's a challenge to keep up with what is a covered benefit and what is not,” says Michael Munger, chairman of the American Academy of Family Physicians who practices in Overland Park, Kansas. He says that many doctors who aren't part of a large health system may not be familiar with dietitians in their community.
For convenience, Munger says, he refers his diabetes patients to a nurse practitioner in his office for nutritional counseling. But only registered dietitians are covered under the Medicare benefit, so his Medicare patients face a copayment for that service.
Jennifer Weis, a registered dietitian in Philadelphia, says the limited number of hours Medicare covers is frustrating given how difficult it is to change behaviors in older adults.
"It's better than nothing, but in my mind is not sufficient,” she says.
Nutritional counseling is not the only underused Medicare benefit that can prevent health complications.
Fewer than 5 percent of Medicare beneficiaries use their benefit of 10 to 12 hours of diabetes self-management training, which can cover individual and group sessions providing tips for eating healthily, being active, monitoring blood sugar, taking drugs and reducing risks.
Part of the problem, says Yoder Latortue, is there is a lot of misinformation about whom the public can trust on nutrition advice.
"Everyone eats and everyone has an opinion,” Yoder Latortue says.
Lauri Wright, a Jacksonville, Florida, registered dietitian and spokeswoman for the Academy of Nutrition and Dietetics, says the federal Centers for Medicare & Medicaid Services (CMS) sends out notices to health providers once a year but more information is needed.
About 10,600 registered dietitians have enrolled to treat Medicare patients, a CMS spokeswoman said. She said the agency has been advising health providers about the benefit and promoting it to enrollees on its website and in its annual handbook sent to beneficiaries.
Still, “I think because only two diseases are covered by Medicare and the rest aren't, it falls off everybody's radar,” Wright says.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.