Friday, July 12, 2019

Retrospective #146: Medicare to Pay for Obesity Counseling

“Medicare to Pay for Obesity Counseling in the Name of Prevention,” trumpeted What a boon for physicians! And what a mixed blessing for their patients! Medicare finally recognized that obesity prevention in the form of counseling, as public health policy, might be as effective as costly gastric bypass surgery. Reducing obesity through “intensive medical nutrition therapy…could produce similar results,” it concluded. But only if your primary care physician “supervised” its administration. This sounds to me like it’s all about the billing.
Medicare reached this conclusion because “It’s almost impossible for physicians to take care of everything. They don’t have the expertise [how true!] or the time” [also true!]. “Seventy-two percent of primary care physicians surveyed…said nobody in their practices had been trained to deal with weight-loss issues.” Yet they [the physicians] say, “unfortunately, those best prepared to provide obesity counseling will not be able to bill directly to do so.”
Why is that? Under the Medicare rules, “those with expertise in the field, such as registered dietitians [?!], are not eligible to bill directly.” Medicare, with perhaps a little lobbying from the AMA, “has limited who is able to bill for those services to primary care physicians, including nurse practitioners, clinical nurse specialists and physician assistants. Medicare will cover services from ‘auxiliary’ providers only if the service is provided in a physician’s office suite and the physician is immediately available to provide assistance and direction.” Yep, it IS all about the billing.
But the consequences for the patient are dire. Registered dietitians and CDE’s, if they follow the training required for certification, are the least qualified persons to provide obesity training, at least to the Pre-diabetic and Type 2 community. This has been my personal experience from attending group counseling for diabetics provided by a CDE/RN at a local health care facility, and years ago with a registered dietitian, plus more recently with a CDE.
Years ago, my doctor employed a registered dietitian in his “office suite.” I remember well her advice to “Eat a ‘balanced’ diet and exercise.” The truth is that she was as ignorant as my doc about the effect on a Type 2 diabetic of eating a “balanced” diet of from 40% to 60% carbs. But my meter provided plenty of feedback, all of it negative.
Forty-five to sixty-five percent carbs is the amount recommended by the Institute of Medicine for everyone in the 2010 Dietary Guidelines for Americans (Table 2-4, pg. 15). The USDA’s Nutrition Facts panel on processed food packaging is likewise a one-size-fits-all formula. Carbohydrates are 1,200 (60%) of the 2,000 calories in the Standard American Diet (SAD,) for a woman. More for a man. And that, folks, is why Type 2 diabetes is a progressive disease!
My experience with a CDE (employed by a doctor) was the result of a silent auction for a non-profit a few years ago. The bidding started at $20, so I placed the first bid, and it was the only bid. At this point I had been eating Very Low Carb for about 10 years. I had lost 170 pounds and had eliminated virtually all my oral diabetes meds. My blood glucose was normal, my blood pressure (on the same meds) had dropped dramatically, and my blood lipids (both HDL and triglycerides) had totally turned around. I no longer had Metabolic Syndrome or detectible hypertension (with meds) or Type 2 diabetes as long as I refrained from eating carbohydrates.
Okay, those conditional statements are caveats, but that is a price I was and am willing to pay for the complete abatement of my symptoms. In doing so I am now at much lower risk of all the Diseases of Civilization to which I was exposed before I began this Way of Eating. It was a rough session, for the CDE, but she toughed it out. In retrospect, it wasn’t very nice of me to do that to her, but maybe it will pay off. Maybe she will have an epiphany.
So “save your money,” so to speak, if counseling is voluntary as it is with Medicare, or just ignore the advice if obesity counseling, also at government expense, is required by the NHS. Your health will be better served if you listen to your meter and avoid any “one-size-fits-all” diet plan.

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