cases, nutrition services are currently covered. However, it is unclear if the type and intensity of nutrition care is consistent with best practice recommendations as indicated by current protocols. For example, prospective payments for renal dialysis continue to include a nutrition component. However, the type and intensity of nutrition care decreased by 21.9 percent between 1982 and 1987. Data are not available to reflect changes since that time. Recently enacted coverage includes important new benefits for diabetes self-management (HCFA, 1999). However, registered dietitians and other nutrition professionals are not directly reimbursable under these new proposed regulations.

Inpatient enteral and parenteral nutrition services are included as part of the hospital prospective payment. For this reason, the committee has not analyzed the economic impact of associated recommendations. However, adherence to best-practice recommendations may create economic burdens for providers that should be considered within Medicare reimbursement and prospective payment policies. In the area of home health, prospective payment systems currently being instituted will be based on current costs. Existing research highlights several ways in which home-bound patients who would be covered under home health care are underserved, and where additional resources may be needed.

EVALUATION METHODOLOGIES

Several criteria have been proposed to evaluate the economic merits of expanded coverage for nutrition services. From a federal budgetary perspective, the simplest criterion is to compute the estimated impact of expanded coverage to overall Medicare expenditures. Congressional mandates require such calculations over a 5-year period to meet overall guidelines designed to constrain the growth of Medicare spending.

Given recent growth in Medicare costs, an analysis of likely expenditures is essential to policy analysis of coverage for nutrition therapy. However, the likely costs of such an expansion must be based on current data. Predicted Medicare expenditures for covered nutrition therapy services require uncertain forecasts of likely patient demands for nutrition services. Existing data suggest that only a small minority of Medicare patients with conditions potentially benefiting from nutrition therapy actually receive these services. The estimates presented below are therefore based on the assumption that the costs (and benefits) of nutrition therapy reflect previously observed patterns of patient service use.

The impact of nutrition services on overall Medicare expenditures is even more difficult to forecast given important interactions between nutrition therapy and other program costs. Expanded Medicare coverage for nutrition therapy is likely to avert clinically significant numbers of strokes



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