Back at her home office in Ossining after a morning therapy session, Roberta Gershner set a working prop in her specialist”™s practice on her desk. It was a sickly yellow, red-tipped mound of manufactured goo that resembled hardened, stomach-turning custard.
“A pound of fat,” Gershner said. A registered dietitian and consulting nutritionist, she also displays cross-sectioned rubber models of plaque-blocked human arteries on her desk.
The cardiac patient she had seen that morning came with some of the time-encrusted bad eating habits she has long encountered over roughly a quarter-century in private practice in Westchester. He complained about giving up tasty white bread for the whole-grain, high-fiber variety that Gershner recommended as part of his medical dietary therapy.
Gershner”™s no-nonsense advice: “Get used to it.”
As a certified dietitian-nutritionist, Gershner, along with her colleagues and business competitors, is poised to serve on the front line of federal health care reform. The focus in the federal Patient Protection and Affordable Care Act on preventive care and employer and community wellness programs to curb health care costs could bring more business to their often overlooked and misunderstood profession.
“We think it”™s going to be positive,” said Jerry Gershner, an Ossining real estate broker who also manages finances in his wife”™s consulting business. The new federal law requires health insurance companies to fully cover preventive services, which include nutritional counseling, for all new and substantially changed policies, he said. However, federal regulators have not yet defined what qualifies as a new or substantially changed policy, he said.
Uncertainty dominates sentiment
Like many health care professionals this fall, Roberta Gershner and her peers are uncertain as to just how the sweeping federal legislation will affect their businesses. They do not know what share they”™ll have in delivering mandated nutrition services. They worry that more aggressive competitors in the weight-loss and dietary markets could outmaneuver them at the smorgasbord of public wellness and prevention programs that has yet to be laid out.
The dietitian”™s role in implementing health care reform at the state level will be the “mega issue” taken up by delegates to the November meeting of the American Dietetic Association. ADA officials have warned members that new federal and state laws and regulations may put them in competition for reimbursement and eligibility standards with other health care providers. In August they issued a call to action to members “to advocate for regulations that protect the public by ensuring strict qualifications for providers.”
Gershner a longtime advocate
Gershner for several years has been an advocate in Albany for her profession and patients. She is a past president of both the New York State Dietetic Association and the Westchester Rockland Dietetic Association. The state group has led an unsuccessful effort to mandate coverage for medical nutrition therapy – the service she provides in her practice – in all health insurance plans in New York, she said. Current state law requires such coverage only for patients diagnosed with diabetes and does not apply to companies with self-insurance plans. Jerry Gershner said New York state employees are not covered under the current law.
The bill backed by the association has sat in committee in the State Legislature for 11 years, Roberta Gershner said. Legislators “don”™t like the word ”˜mandate,”™” she said.
“I think it”™s a barrier to health,” she said of the state”™s failure to require the nutritional therapy coverage for all insurance policies. “I think it”™s costing the state a lot of money to say, hey, we”™ll take off your leg, but we won”™t pay for a dietitian.”
Dietitians push for state licensing
Though registered by their national association, Roberta Gershner and her colleagues in New York are prodding the state to require licensing for their profession. In New York, “Your manicurist is licensed,” she said. “Your barber is licensed. But your dietitian, we”™re still not licensed,” though the skilled work includes mixing dietary formulas for patients and applying food science. “It”™s a matter of public protection, protection for the patient, to enable the dietitian to be licensed,” she said.
Roberta Gershner said the licensing effort in Albany began in the ”™90s and more recently has stalled over wording acceptable to both the ADA and the state”™s licensing arm in the state Department of Education. She said the licensing requirement has been opposed by dietary-supplement companies and health food stores that dispense nutritional advice with their consumer products.
“Maybe we”™re not vocal enough,” she said. “I”™ll be happy if I”™m able by the time I die to see this passed.”
Insurers understand cost efficiency
In New York, “Most insurance companies cover nutrition,” said Jerry Gershner, “not out of the goodness of heir heart, but because they know it”™s cost-efficient.” Claim reimbursements from health insurers such as Aetna, Oxford and Cigna make up about 85 percent of revenue in his wife”™s practice, he said.
The reimbursement fees paid by insurers to his wife “are all over the place,” he said. “No two companies are the same.”
“And they”™re going down,” Roberta Gershner said. “Health costs are going up and our fees are going down.”
Doctors offer the most referrals
For Roberta Gershner and other dietitians in private practice, physicians are their best customers. “By and large, the patient for a practice such as this, as with any specialist, is referred by a physician,” Jerry Gershner said. His wife, who in the 1980s was one of the first dietitians in Westchester and the state to open a private practice, works with a network of physicians in the county.
Yet that insurance coverage only applies to patients diagnosed with chronic diseases for which dietary changes are recognized as helpful treatment, Roberta Gershner said. The federal reform bill allows that disease-based coverage to be expanded for Medicare patients, who currently are covered only when diagnosed with diabetes or kidney disease.
Roberta Gershner said some patients do not follow through on their doctors”™ referrals to her. Their co-payer”™s share of the nutritionist”™s bill could be keeping them away, especially as many insurers have raised co-pay rates for specialist visits, the Gershners said. Co-payments for preventive services such as nutrition counseling stand to be eliminated under the new federal law.
The prospect of increased demand for her services as health care reforms unfold is shadowed by what Roberta Gershner sees today in the nation. “We talk about health on one side of our mouth, but we don”™t arm our citizenry with the education we need to stay healthy,” she said. Youths at an early age must be taught healthy eating habits “without the idea that it”™s punitive,” she said.
