Registered dietitians (RDs) are becoming an increasingly important part of many endocrinology practices. Although most often thought of in relation to patients with diabetes, RDs also can impact the treatment of other endocrine diseases where weight gain is a problem.
“A lot of what we do in this specialty is education, counseling, and coordination of care,” says Farha Kahn, MD, FACE, an endocrinologist with Allina Medical Clinic in Coon Rapids, MN. “Most physicians don’t have the time to spend an hour or two with each of our patients to go through meal plans and do the needed education. I think having an RD becomes a necessity for those practices that have the volume to support them.”
An RD’s time is used to help the patient craft a nutrition plan that looks at their personal needs, likes, and dislikes, and educates them to help the patient stay on the plan going forward.
Outcome Impacts
A reason to look at the possibility of bringing dietitians into the practice is that they have been shown to have a major impact on patient-centered outcomes. A study published in 2008 in Diabetes Care showed that RD involvement in a comprehensive diabetes education program can be linked to 34% fewer diabetes-related hospitalizations and better hemoglobin A1c control.
“With tight blood glucose control, we have seen definite decreases in the risk for comorbidities such as amputations and heart disease,” notes Kristi L. King, RD, a spokesperson for the Academy of Nutrition and Dietetics. “Having an RD involved helps the patient to find a diet that works in the life of the specific person and not be part of a cookie-cutter diet. The benefit is being able to put together a plan that addresses the needs, likes, and dislikes of a particular patient.”
Adding an RD to the practice requires study and planning. Getting reimbursed for their services can be tricky. The government programs will generally pay for dietitian services for certain diagnoses; the private insurers are much more varied in this area.
Better Care
“I don’t think there is any argument that an endocrinology practice is more complete with an RD and the patient gets better care,” says Damon Tanton, MD, medical director at the Florida Hospital Diabetes Institute in Orlando. “But you have to be very diligent in the way that you use them, making sure that the patient they are seeing is one you can actually get paid for.”
He thinks the easiest way to decide if having an RD is right for your practice is looking at your Medicare census.
“With commercial insurance, there is just too much variation in not only if they will pay for a service, but also how much,” says Tanton. “If I can pay for the RD from Medicare, any money I get from the private payers will be icing on the cake.”
Certified Diabetes Educators
Jaime Lehman, RD, CDE, with Banner Health in Peoria, Ariz., suggests that endocrine practices consider using an RD who is also a certified diabetes educator (CDE). Dietitians with this credential are well versed in all aspects of diabetes management, from nutrition to insulin management. Theycanserveas a liaison between the patient and the physician while working with the patient to improve clinical incomes. This can free physicians up to see more patients. A skilled RD could actually allow the practice to add new patients and grow relatively cheaply.
Dietitians seeking further income streams and billable hours can apply for program accreditation from the American Diabetes Association (ADA) or American Association of Diabetes Educators (AADE). In addition to initial and annual nutrition counseling, this accreditation gives the practice an opportunity to bill for comprehensive and ongoing diabetes education. Most of these sessions can be done in a group setting (see “Happy Together,” p. 30, October 2013, Endocrine News), which increases the efficiency of service delivery for the practice.
The calculus on using RDs may change as healthcare reform continues. As pay for performance, accountable care organizations, and Medical Home concepts go forward, the proven impact RDs can have on hospitalizations, lowering complication rates, and other factors may bring added benefits to the practice.
“If I was advising a colleague, I would say that they are going to get benefits that aren’t readily seen in your cost/benefit analysis,” Tanton says. “I think we should also factor in some of these other things when looking at an RD’s worth to the practice. You know these models aren’t going to go away and will have an effect on you for many years.”
Adding RDs
RDs will become a bigger part of endocrine practices going forward. Bigger practices will be looking at adding them as staff . Smaller or solo practices may have to be more creative. Partnerships with other groups where they “share” a person is one option. In other cases, “borrowing” a dietitian from the hospital may be an avenue to these services.
The experts agree that endocrinology isn’t like some other specialties where the patient is given a shot or has something taken out and sent on his or her way. It is much more focused on counselingandteaching,especially when working with diabetes patients.
“Most physicians just don’t have the time to spend an hour or two with each patient helping them figure out how many calories they should be burning and how they should do it,” Khan says. “RDs and CDEs help us get back to nutrition counseling, which really is the underpinning of medicine in our specialty.”
— Kurt Ullman, RN, MHA, is an Indiana-based freelance writer with nearly 30 years of experience. He wrote about the Physician Quality Reporting Initiative in the November 2013 issue.
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