THE MARYLAND ACADEMY OF NUTRITION AND DIETETICS Recommendations For: Maximizing the Cost- Effectiveness of Maryland s State Health Insurance Benchmark Plan November 2012 11/16/2012
OVERVIEW The Maryland Academy of Nutrition and Dietetics (MAND), formerly known as the Maryland Dietetic Association, is an organization of registered dietitians (RD), licensed dietitiannutritionists (LDN), and dietetic technicians registered (DTR) residing, and working in the state of Maryland. Affiliated with the Academy of Nutrition and Dietetics, MAND has over 1,200 members. There are over 2,700 registered dietitians in Maryland. Registered Dietitians: Who We Are Registered dietitians are intrinsically focused on prevention and chronic disease treatment and management. They provide vital nutrition services while promoting health and well-being to the public. RDs use their expertise to help individuals make unique, positive lifestyle changes. They provide care by applying the Academy of Nutrition and Dietetics Evidenced-based Nutrition Practice guidelines. The guidelines illustrate best practices for medical nutrition therapy (MNT) related to specific diseases or conditions to achieve positive outcomes. Data show that MNT is linked to improved clinical outcomes and reduced costs related to physician time, medication use and hospital admissions for people with obesity, diabetes, disorders of lipid metabolism, as well as other chronic diseases. i RDs are the most cost-effective, qualified healthcare professional to provide MNT. MNT is distinctly different than nutrition education and requires advanced skills beyond those of other professionals. RDs must complete a minimum of a bachelor s degree in nutrition, participate in a practice program involving direct patient interaction and pass a national registration exam. Approximately 50% of RDs hold advanced degrees. RDs are also required to complete continuing professional education to maintain their credential. According to the Institute of Medicine, the registered dietitian is currently the single identifiable group of health care professionals with standardized education, clinical training, continuing education and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy. ii The U.S. Preventive Services Task Force recommends intensive nutrition counseling for cardiovascular and diet-related chronic disease delivered by clinicians including registered dietitians. The Role Nutrition Plays in Disease The role of nutrition in health promotion, disease prevention and disease management has become a progressively more significant public health issue. Overweight and morbid obesity runs rampant in the United States. In fact, it is considered to be one of the leading causes of deaths of adults. iii In preventing chronic diseases, nutrition and diet must be incorporated into a daily regimen. The 1 P a g e
importance of nutrition is underscored by the role of nutrition in the prevention of the leading causes of death including cardiovascular disease, type 2 diabetes, hypertension, osteoporosis, and certain cancers. iv Four of the top six leading causes of death, diseases of the heart, cancer, cerebrovascular disease and diabetes can be influenced by diet. According to a published survey, over 94% of primary care physicians agree that nutrition is a significant factor in the prevention, treatment and management of chronic diseases. v MNT Providing Return on Investment Why have we taken the time to establish the unique qualifications and expertise of registered dietitians in the field of nutrition and to show the connection between nutrition and disease? Because nutrition related diseases cost money and registered dietitians save money. The benefits of investing in access to MNT by registered dietitians was acknowledged in 2000 when the U.S. Medicare program extended provider privileges to registered dietitians to provide medical nutrition therapy to beneficiaries diagnosed with diabetes or renal disease. In 2008, U.S. medical costs associated with obesity were estimated at $147 billion, the medical costs for people who are obese were $1,429 higher than those of normal weight. vi That s almost 10% of medical spending most of which is generated from treating obesity-related diseases such as diabetes. vii Diabetes and obesity are associated with elevated rates of lost productivity and disability. In 2007, people with diabetes lost 15 million days of work due to diabetes, costing the U.S. economy approximately $2.6 billion. viii A modest-cost registered dietitian-led lifestyle intervention provided to people with diabetes and obesity reduced the risk of having lost work days by 64.3% and disability days by 87.2% compared with those receiving usual medical care. For every dollar an employer invests in the lifestyle modification program for employees with diabetes, the employer would see a return of $2.67 in productivity. ix Data show, that the application of medical nutrition therapy by registered dietitians to adults who are obese or overweight for less than six months resulted in weight loss of approximately 1-2 pounds per week. When provided between 6 to 12 months, MNT resulted in a weight loss of up to 10% of body weight and continued maintenance beyond one year. x Multiple studies conclude that MNT produces improved clinical outcomes and reduces health care costs for individuals with obesity and diabetes. xi Studies from the Academy of Nutrition and Dietetics Evidence Analysis Library states that when MNT is provided between 3 to 6 months by a registered dietitian, patients experienced a reduction on A1C ranging from 0.25% to 2.9%; MNT applied for 12 months show either sustained or improved outcomes. The Lewin group documented a 9.5% reduction in hospital utilization and a 23.5% reduction in physician visits when MNT was provided to persons with diabetes mellitus. xii 2 P a g e
The benefits of MNT by a registered dietitian are not limited to obesity and diabetes. The Lewin Group documented an 8.6% reduction in hospital utilization and a 16.9% reduction in physician visits with patients with cardiovascular disease who had access to MNT services. xiii Massachusetts General Hospital reported that participants receiving group MNT in a 6-month randomized trial had a 6% decreased in total LDL-cholesterol levels. The group not receiving MNT had no reduction in total cholesterol or LDL levels. The study revealed a savings of $4.28 for each dollar spent on MNT, much less than the cost of statin therapy. xiv Prenatal nutrition programs that target high-risk pregnant women have been shown to improve long-term health outcomes in children, saving at least $8 for each dollar invested in the program. xv Maryland s Numbers Maryland ranks 22 nd in the nation in obesity with a rate of 28.3% xvi Adult Obesity Rate in Maryland Could Reach 58.8% by 2030, according to F as in Fat: How Obesity Threatens America's Future 2012, a report released September 2012by Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation (RWJF). Related Health Care Costs Could Climb by 21.3 Percent xvii The analysis, which was commissioned by TFAH and RWJF and conducted by the National Heart Forum, is based on a peer-reviewed model published last year in The Lancet. The analysis also shows that states could prevent obesity-related diseases and dramatically reduce health care costs if they reduced the average body mass index of their residents by just 5%by 2030. Other findings are below: Over the next 20 years, obesity could contribute to 741,358 new cases of type 2 diabetes, more than 1.5 million new cases of coronary heart disease and stroke, 1.4 million new cases of hypertension, 968,487 new cases of arthritis, and 222,932 new cases of obesity-related cancer in Maryland. By 2030, obesity-related health care costs in Maryland could climb by 21.3%, which could be the seventh highest increase in the country. If BMIs were lowered by 5%, Maryland could save 7.6% in health care costs, which would equate to savings of over 13.8 billion dollars by 2030 (13,836,000,000). The number of Maryland residents who could be spared from developing new cases of major obesity-related diseases includes: 158,413 people could be spared from type 2 diabetes, 129,330 from coronary heart disease and stroke, 3 P a g e
126,707 from hypertension, 70,406 from arthritis, and 10,841 from obesity-related cancer One of the key recommendations of the report is encourage full use of preventive health care services and provide support beyond the doctor s office. Obesity-Related Health Care Costs in Maryland Potential Savings by 2020 if BMI is Reduced by Potential Savings by 2020 if BMI is Reduced by 5% 5% $4,935,000,000 $13,836,000,000 Potential Health and Cost Savings by Top Obesity-Related Health Problems 2010 Number Potential Cases Potential Costs Potential Cases Potential Costs of Cases Avoided by 2020 if BMI is Savings by 202 if BMI is Avoided by 2020 if BMI is Savings by 202 if BMI is Type 2 Diabetes 469,294 79,731 $1,580,000,000 158,413 $5,211,000,000 Obesity-Related 86,375 5,537 $156,000,000 10,841 $339,000,000 Cancers* Coronary Heart 320,731 63,295 $2,408,000,000 129,330 $6,099,000,000 Disease & Stroke Hypertension 1,083,304 71,397 $338,000,000 126,707 $930,000,000 Arthritis 1,098,166 37,884 $458,000,000 70,406 $1,262,000,000 2010 baseline for potential cases, costs and savings *National Heart Forum provided the total cases and cases avoided per 100,000 people and the TFAH used the state s 2011 census data to translate to the full population based estimates xviii MAND s HEALTH INSURANCE EXCHANGE PROPOSAL Given the observations of the role nutrition plays in managing chronic disease, and the current and projected numbers for Maryland, it is necessary that MNT be included in the essential health benefits for Maryland Health Insurance Exchange. RDs are the most qualified practitioners to provide such services given their expertise and training. By providing MNT by RDs in conjunction with existing services covered by insurance carriers, there will be a significant impact on chronic disease management along with significant cost-savings. The Maryland Academy of Nutrition and Dietetics recommends that the Committee includes access to nutrition services for children and adults in the form of Medical Nutrition Therapy provided by registered dietitians (RDs). 4 P a g e
i American Dietetic Association Evidence Analysis Library. Medical Nutrition Therapy Evidence Analysis Project 2008. Accessed May 2010, https://www.adaevidencelibrary.com/topic.cfm?cat=3675. ii Committee on Nutrition Services for Medicare Beneficiaries. The Role of Nutrition in Maintaining Health in the Nation s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: Food and Nutrition Board, Institute of Medicine; January 1, 2000 (published). iii Flegel KM, Carroll M, Ogden C, Johnson CL. (2002). Prevalence and trends in overweight among US adults, 1999-2000. J Amer Med Assoc, 288(14): 1723-1727, 2002; Ogden CL, Flegel KM, Carroll MD, Johnson CL. (2002). Prevalence and Trends in Overweight Among US Children and Adolescents, 1999-2000. J Amer Med Assoc., 288 (14): 1728-1732; Mokdad AH, Marks JS, Stroup DF, Gerberding JL. (2004). Actual causes of death in the United States, 2000. J Amer Med Assoc., 291(10): 1238-1245; The Surgeon General s Call To Action To Prevent and Decrease Overweight and Obesity http://surgeongeneral,gov/topics/obesity/default.htm. iv American Diabetes Association. Nutrition Principles and Recommendations in Diabetes. Diab Care 27:S36-S46, 2004; Brown J, Byers T, Thompson K et al. Nutrition during and after cancer treatment. CA Cancer J Clin 2001;51:153-187; Byers T, Nestle M, McTiernan et al. Guidelines on nutrition and physical activity for cancer prevention. CA Cancer J Clin 2002;52:92-119; National Cancer Institute. National Institute of Health. Overview of Nutrition in Cancer Care. http://www.nci.nih.gov/cancertopics/pdq/supportivecare/nutrition. Accessed December 28, 2004; NIH Publication No. 03-4082, Facts about the DASH Eating Plan, United States Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/; Public Health Service, United States Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville MD: Office of the Surgeon General, October 2004. v The Role of Nutrition in the Treatment and Management of Chronic Disease: A Survey Among Primary care Physicians, Hart Research Associates, June 2009 vi http://content.healthaffairs.org/content/28/5/w822.full.pdf+html vii http://healthyamericans.org/report/98/obesityratesbystate viii American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596 615. [PubMed: 18308683]. ix Wolf AM, Siadaty MS, Crowther JQ, et al. Translating Lifestyle Intervention on Lost Productivity and Disability: Improving Control with Activity and Nutrition (ICAN). J Occup Environ Med. 2009 February;51(2):139 145. x ADA MNT ToolKit: Grade 1 data: ADA Evidence Analysis Library, http://www.adaevidencelibrary.com/topic.cf,?cat=3949, April 2010 xi Academy of Nutrition and Dietitics Evidence Analysis library; http://andevidencelibrary.com/default.cfm xii What does it tell us, and why does it matter? The Lewin Group, Johnson Rachel. J Am Diet Association 1999;99:426-427 xiii What does it tell us, and why does it matter? The Lewin Group, Johnson Rachel. J Am Diet Association 1999;99:426-427 xiv Delahanty LM, Sonnenberg LM, Hayden D, Nathan DM. Clinical and cost outcomes of medical nutrition therapy for hypercholesterolemia: A controlled trial. J Am Diet Assoc. 2001;101:1012 1016. xv Duquette MP, Payette H, Moutquin JM, Demmers T, Desrosiers-Choquette J. Validation of a screening tool to identify the nutritionally at-risk pregnancy. J Obstet Gynaecol Can. 2008 Jan;30(1):29 37. xvi http://www.cdc.gov/obesity/data/adult.html xvii http://healthyamericans.org/reports/obesity2012/?stateid=md xviii http://healthyamericans.org/assets/files/obesity2012/tfahsept2012_md_obesitybrief02.pdf 5 P a g e