The Role of Nutrition in Maintaining Health in the Nation's Elderly Evaluating Coverage of Nutrition Services for the Medicare Population (2000) / Chapter Skim
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1 Introduction
1 Introduction
Pages 23-45
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Section I Introduction and Overview
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The OTA analysis considered scientific and clinical issues but were also explicitly intended to provide guidance to policymakers by examining the cost-effectiveness of clinical interventions, possible costs to Medicare of extending coverage, and other policyrelevant issues. For categories of covered services, Congress has authorized the Health Care Financing Administration to establish procedures for making more specific decisions about individual services within the broad categories established legislatively.
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Changes in health care since the inception of Medicare in 1965 have had a significant impact on the delivery of nutrition services to Medicare beneficiaries. The shift from traditionally delivered inpatient care to ambulatory care has reduced the number of hospital beds and increased the severity of illness in the remaining hospitalized patients.
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Yet, with careful planning, these non-acute care settings may be better suited, along with the traditional outpatient office setting, to deliver the nutrition services needed by Medicare beneficiaries. Scientific advances in medical care have increased the need for a multidisciplinary team approach to patient care and a shift from the individual provider model.
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Experts in areas selected by the committee were invited to make presentations and discuss evidence related to particular elements of nutrition services as well as behavioral considerations in the elderly population. During the workshop, a public comment period was held, and interested individuals and organizations were invited to present both oral and written testimony to the committee.
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Nutrition therapy includes oral, enteral, and parenteral nutrition interventions and takes into consideration the cultural, socioeconomic, and food preferences of the individual. Even though the population of Medicare beneficiaries includes a significant number of individuals younger than 65 years of age with disabilities (about 13 percent)
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, acute care hospitals (inpatient care) , sub-acute and long-term care facilities, and home care.
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. With certain exceptions, Congress explicitly excluded coverage for preventive services, outpatient prescription drugs, dental care, and long-term nursing home care and other supportive services for people with chronic disabling conditions.
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5In 1997, as part of the Balanced Budget Act, congress created Part c Also known as Medicare+Choicey, which restructured and expanded options for Medicare beneficiaries to enroll in approved health maintenance organizations and other private health insurance plans. These plans, which are paid a fixed monthly amount per enrolled beneficiary, must provide Medicare-covered services but may also offer additional benefits.
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It also covers a number of additional services such as outpatient hospital care, outpatient dialysis services, clinical laboratory tests, durable medical equipment, ambulance services and, since 1997, most home health care services. For part B coverage, beneficiaries pay a monthly premium (set to cover 25 percent of Part B expenditures or $45.50 per beneficiary in 1999)
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may be eligible for additional preventive and other services, sometimes by paying an additional premium, but HMOs vary greatly in the extent to which they offer benefits not required by Medicare (Kaiser Family Foundation, 1998~. Enrollment and Expenditure Trends Since the program was implemented, the number of Medicare beneficiaries has roughly doubled, from 19.1 million when the program began in 1966 to approximately 38.4 million for 1997 (about 4.8 million of whom qualify for Medicare due to disability and about 0.3 million due to ESRD)
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. MEDICARE COVERAGE DECISIONS6 Medicare coverage decisions range from very broad-based decisions about whole categories of services to very narrow decisions about whether a specific service will be covered for a specific individual.
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Health Care Financing Administration Within the broad coverage categories established by Congress, more specific determinations about what services are or are not covered are the responsibility of the Health Care Financing Administration (Bagley and McVearry, 1998~. HCFA also provides detailed guidance to Medicare contractors regarding the application of its coverage rules and the development of local contractor medical policies for situations not dealt with by such rules.
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In making coverage determinations, HCFA must follow federal rulemaking procedures and requirements. After criticism that agency procedures violated federal open government rules, HCFA created a new Medicare Coverage Advisory Committee, for which administrative procedures are being developed and reviewed.7 A typical candidate for the committee review would be a new technology or new use of an established technology relevant to an existing coverage category.
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HCFA uses another group of contractors, Peer Review Organizations (PROs) to conduct prior reviews of certain surgical procedures and engage in other activities intended to improve the quality of care provided to Medicare beneficiaries.
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The information is somewhat simplified and does not reflect all possible instances but serves as the general assumptions of current coverage by the committee. TABLE 1.1 Medicare Coverage of Nutrition Services Service General Coverage Nutrition Services Coverage MEDICARE PART A Hospital inpatient care Medicare reimburses hospitals a bundled payment, based on diagnosis, for all services provided by the facility, including bed and board, nursing and related services, diagnostic and therapeutic services, drugs, and supplies.
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care Medicare pays SNFs a per diem payment that covers bed and board, nursing and related services, therapeutic services, drugs, and supplies. services, parenteral and enteral fluids.
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counseling is included in the per diem rate and is not reimbursed as a separate charge. MEDICARE PART B Health care provider Medicare pays physicians Nutrition services provided visits and certain other health by health professionals care professionals (e.g., recognized by Medicare as dentists, chiropractors, "certified providers" may optometrists, podiatrists, receive reimbursement if advanced practice nurses, the service is deemed physician assistants, reasonable and medically psychologists, social necessary.
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Registered dietitians in independent practice are not authorized by Medicare to receive reimbursement for providing nutrition services. Hospital outpatient Medicare has in the past Nutrition services provided department care reimbursed hospital as part of a patient outpatient departments on educational program, such a cost basis.
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Payment is made for professional services or for laboratory tests according to the applicable fee schedule. Home health services reimbursed under Part B include those not related to an inpatient stay or visits in excess of 100 following an inpatient stay.
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Under the conditions for coverage, each facility must provide dietetic services to meet the needs of patients; employ or have a contractual relationship with a qualified dietitian who, in consultation with the attending physician, assesses the nutritional and dietetic needs of each patient, recommends therapeutic diets, counsels patients and their families on prescribed diets, monitors adherence and response to prescribed diets, and records findings in the patient's medical record. The full range of dialysis services, including personnel services for dietitians, is covered under the composite rate.
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1998b. Medicare program; Establishment of the Medicare Coverage Advisory Committee and request for nominations for members.
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1990. Preventive Health Services for Medicare Beneficiaries: Policy and Research Issues.
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