Overview of Key Findings   In 2016, 21.8% of the fee-for-service (FFS) Medicare population resided in a rural county, but only 3.7% of enrollees residing in a county with utilization of Medical Nutrition Therapy (MNT) services were rural county residents. Utilization of MNT services in 2016 occurred in 92 rural counties and 388 urban counties. Average utilization rates of MNT services were greater in rural counties than urban counties (3.1% vs. 1.9%)

Rhudy, Christian

Shin, Eugene

Talbert, Jeffery C.

English

University of Kentucky

UKnowledge University of Kentucky UKnowledge Rural & Underserved Health Research Center Publications Rural & Underserved Health Research Center 6-2020 Rural/Urban Disparities in Utilization of Medical Nutrition Therapy to the Fee-for-Service Medicare Population Christian Rhudy University of Kentucky, christian.rhudy@uky.edu Eugene Shin University of Kentucky, eugenes@uky.edu Jeffery C. Talbert University of Kentucky, jeff.talbert@uky.edu Follow this and additional works at: https://uknowledge.uky.edu/ruhrc_reports  Part of the Health Services Administration Commons, and the Health Services Research Commons Right click to open a feedback form in a new tab to let us know how this document benefits you. Repository Citation Rhudy, Christian; Shin, Eugene; and Talbert, Jeffery C., "Rural/Urban Disparities in Utilization of Medical Nutrition Therapy to the Fee-for-Service Medicare Population" (2020). Rural & Underserved Health Research Center Publications. 13. https://uknowledge.uky.edu/ruhrc_reports/13 This Policy Brief is brought to you for free and open access by the Rural & Underserved Health Research Center at UKnowledge. It has been accepted for inclusion in Rural & Underserved Health Research Center Publications by an authorized administrator of UKnowledge. For more information, please contact UKnowledge@lsv.uky.edu.  This project was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement # U1CRH30041. The information, conclusions and opinions expressed in this document are those of the authors and no endorsement by FORHP, HRSA, HHS, or the University of Kentucky is intended or should be inferred.  ©2020 Rural & Underserved Health Research Center, University of Kentucky   Gr   Rural/Urban Disparities in Utilization of Medical Nutrition Therapy to the Fee-for-Service Medicare Population Christian Rhudy; Eugene Shin; Jeffery Talbert, PhD  Overview of Key Findings ▪ In 2016, 21.8% of the fee-for-service (FFS) Medicare population resided in a rural county, but only 3.7% of enrollees residing in a county with utilization of Medical Nutrition Therapy (MNT) services were rural county residents. ▪ Utilization of MNT services in 2016 occurred in 92 rural counties and 388 urban counties. ▪ Average utilization rates of MNT services were greater in rural counties than urban counties (3.1% vs. 1.9%).  Introduction  In the treatment of many disease states and conditions, lifestyle and dietary changes can be important to achieve positive outcomes. In order to guide effective dietary changes, patients with renal disease or diabetes can be provided Medical Nutrition Therapy (MNT). MNT involves the development of a nutrition plan for a patient with a physician or dietitian that is appropriate for the patient’s condition or disease state.1 After an assessment of the client, MNT involves determining the nutritional needs of the patient and prescribing a diet that will offer optimal outcomes.  MNT plays an important role in the treatment of a variety of chronic conditions, including diabetes mellitus, hypertension, obesity, and chronic kidney disease.2-5 Usage of MNT services has been shown to decrease hemoglobin A1c values by 1%-2% in patients with diabetes mellitus,2 while also reducing systolic blood pressure up to 10 mmHg in hypertensive patients.3 Patients receiving MNT were also approximately twice as likely to obtain a clinically significant reduction in weight and were more likely to exercise more frequently.4 Utilization of MNT in patients with chronic kidney disease was observed to delay dialysis and slow decline in kidney function.5 Medicare reimburses up to three hours of MNT services within the first year of diagnosis of either renal disease or diabetes. After the first year, Medicare will cover two further hours of MNT services per year.6 Despite the effectiveness of MNT, comparatively low utilization rates have been observed in populations with certain disease states (such as diabetes mellitus).7 Additionally, differences in utilization and compliance with MNT-recommended regimens have been observed along socioeconomic and gender demographic lines.7-8       Policy Brief               June 2020 University of Kentucky 760 Press Ave. Suite 360 Lexington, KY 40536 ruhrc.uky.edu Disparities in Provision of MNT  Policy Brief Rural & Underserved Health Research Center  Page 2 One potential variable affecting MNT utilization in the United States that has not yet been examined is the utilization of MNT services in rural versus urban communities. The objective of this study was to identify the utilization of MNT services in rural and urban communities by examining the population of Medicare fee-for-service (FFS) beneficiaries in 2016. Methods The Medicare Physician and Other Supplier Public Use File (PUF) provides information on services and procedures provided to FFS Medicare beneficiaries by physicians and other health care providers (including pharmacies and nurse practitioners).9 The PUF data contain information on utilization, payment, and charges by National Provider Identifier (NPI), Healthcare Common Procedure Coding System (HCPCS) code, and provider type for all providers delivering services to FFS Medicare beneficiaries. At the time of the study, 2016 was the most recent PUF available. The 2016 Medicare provider data were extracted and HCPCS codes G0270 and G0271, as well as CPT codes 97802-97804, were used to determine the number of units of MNT services provided, the number of health care providers administering the service, and the number of beneficiaries served by each provider. Provider services and beneficiaries were then aggregated at the county level using provider location data. Rural-Urban Continuum Codes (RUCCs) were used to assign counties to rural versus urban designations, with codes 1-3 designated as urban and codes 4-9 designated as rural.10 The 2016 FFS Medicare enrollment data,11 as well as diabetes and chronic kidney disease (CKD) incidence rates,12 were observed in aggregate and applied at the county level to calculate potentially eligible enrollees and MNT utilization rates.  Findings In 2016, FFS Medicare enrollees increased to 33.9 million (Table 1), with an approximate 4:1 ratio of enrollees residing in urban (RUCC 1-3) to rural (RUCC 4-9) counties. In this population, 9.2 million (27.3%) had diabetes, while 7.6 million (22.3%) had chronic kidney disease. Among FFS beneficiaries, 6.5 million (19.4%) had comorbid diabetes and CKD, which represents 38.9% of FFS beneficiaries with either diabetes or CKD. When examined separately, the ratio of urban to rural residence in enrollees with diabetes or CKD was comparable to the same ratio for the total FFS population.  Table 1. Rural/Urban Enrollment in FFS Medicare Nationwide and in Counties Providing MNT Services, 2016  2016 Nationwide Medicare FFS enrollees    RUCC 1-3 (Urban) RUCC 4-9 (Rural) Category Total Enrollees Percentage Enrollees Percentage All 33,851,996 26,455,562 78.2% 7,396,434 21.8% With Diabetes 9,247,673 7,245,302 78.3% 2,002,371 21.7% With CKD 7,562,534 6,024,435 79.7% 1,538,099 20.3% With Diabetes and CKD 6,533,747 * * * * 2016 Medicare FFS Enrollees in Counties Where MNT Services Were Utilized All 19,410,855 18,697,835 96.3% 713,020 3.7% With Diabetes 5,300,610 5,117,576 96.5% 183,034 3.5% With CKD 4,419,866 4,276,853 96.8% 143,013 3.2% Eligible Enrollees* 5,939,208 5,739,993 96.6% 199,215 3.4%  *Comorbidity rates of diabetes and CKD were unavailable at the county level. Eligible enrollees were estimated utilizing the sum of beneficiaries with CKD/Diabetes less the national comorbidity average of 39.8%.   Disparities in Provision of MNT  Policy Brief Rural & Underserved Health Research Center  Page 3  Of all FFS Medicare enrollees in 2016, over half (19.4 million, 57.3%) resided in counties where MNT services were utilized. In these counties, 5.3 million (27.3%) FFS beneficiaries had diabetes, while 4.4 million (22.8%) had CKD. This group of enrollees resided predominantly in urban counties (96.3%). In subsets with diabetes or kidney disease, no marked differences in proportions of urban to rural residence were observed. The estimated number of eligible enrollees in counties utilizing MNT services was 5.9 million (30.6%). This estimate was calculated by adding the number of county enrollees with diabetes and CKD less the number of beneficiaries with comorbid CKD and diabetes. Because comorbidity rates were not publicly available at the county level, the number of beneficiaries with comorbid CKD and diabetes was estimated using the national average (39.8% of summed CKD/diabetes enrollees). In 2016, 1,533 unique providers administered 405,105 units of MNT services to 92,392 unique beneficiaries (Table 2). MNT beneficiaries utilized a mean 4.4 units of MNT services in 2016. Beneficiaries in rural counties utilized fewer units of MNT services on average (4.0 units) than those in urban counties (4.4 units). While there is no clinical recommendation for the amount of MNT a patient should receive as treatment is highly individualized, this does suggest that rural beneficiaries receive shorter or fewer sessions of MNT.12 The average MNT provider administered 264.3 units of MNT. MNT providers practicing in urban counties administered more than the national average (270.6 units), while rural providers typically administered significantly less (185.4 units). Table 2. FFS Medicare MNT Providers, Service Hours and Beneficiaries in 2016 Category Total RUCC 1-3 (Urban) RUCC 4-9 (Rural) Providers 1,533 1,418 115 Service Units 405,105 383,779 21,326 Beneficiaries 92,392 87,116 5,276 Average County Utilization Rate 2.1% 1.9% 3.1%  County utilization rates were calculated as the number of Medicare FFS beneficiaries utilizing MNT services in a county divided by the estimated number of eligible enrollees in that county. The average county utilization rate for the total population was 2.1%. Rural counties on average had a higher utilization rate (3.1%) than urban counties (1.9%).  Figures 1 and 2 display diabetes and chronic kidney disease prevalence by county in the FFS Medicare population. This can be compared to the actual utilization of MNT services at the county level, as displayed in Figure 3. Disease prevalence appears to be greatest in the Southeast, but services are more localized to the Northeast and Midwest. Interactive maps depicting MNT providers, service hours, beneficiaries, and utilization rates at the county level can be found at https://ruhrc.uky.edu/infographics/.   Disparities in Provision of MNT  Policy Brief Rural & Underserved Health Research Center  Page 4 Figure 1. Diabetes Prevalence in the FFS Medicare Population in 2016  Figure 2. Chronic Kidney Disease Prevalence in the FFS Medicare Population in 2016  Disparities in Provision of MNT  Policy Brief Rural & Underserved Health Research Center  Page 5  Figure 3. Utilization of MNT Services in the FFS Medicare Population in 2016   Prevalence data from a total of 3,140 counties were observed, and utilization of MNT services was observed to occur in 480 counties (Table 3). While the average prevalence of chronic kidney disease/diabetes is relatively similar across rural and urban counties, MNT services were utilized in many more urban counties (388, 80.8%) than rural (92, 19.2%). When taken in the context of the overall greater number of rural counties (1,975 compared to 1,165), the disparity is even more striking.   Disparities in Provision of MNT  Policy Brief Rural & Underserved Health Research Center  Page 6  Table 3. County Utilization of MNT Services as Compared to Average County DM/CKD Prevalence, 2016   All Counties Category Number of Counties Average Incidence of Diabetes Average Incidence of CKD Total 3,140 26.8% 21% Urban (RUCC 1-3) 1,165 27.1% 22.2% Rural (RUCC 4-9) 1,975 26.6% 20.2%   Counties Utilizing MNT Total 480 26.2% 21.8% Urban (RUCC 1-3) 388 26.5% 22.3% Rural (RUCC 4-9) 92 25.3% 19.8%   Counties without MNT Utilization Total 2,660 26.9% 20.9% Urban (RUCC 1-3) 777 27.4% 22.2% Rural (RUCC 4-9) 1,883 26.7% 20.2%  Conclusion/Discussion Based upon the observed patterns of MNT utilization, significant differences exist between rural and urban utilization. In counties where MNT services are utilized, utilization rates are higher in rural counties as compared to urban counties. However, utilization of MNT services occurs in far fewer rural counties than urban counties, and it occurs in lesser amounts per beneficiary as compared to urban utilization. The lack of utilization in rural counties cannot be explained by lower disease incidence and is not proportional to the rural segment of the FFS Medicare population. Low utilization in rural areas may be explained by a lack of rural access, or rural beneficiaries traveling to urban locations for treatment; however, these conditions could not be examined. Regardless of etiology, the lower utilization of MNT services in rural counties may lead to an outcome disparity as compared to urban counties. Finding methods to provide more MNT services to rural populations, via innovative health care organization structure or technology, may be key in addressing this observed disparity.  References 1. Larson E. MNT (medical nutrition therapy): an innovative employee-friendly benefit that saves. J Am Diet Assoc. 2001;101(1):24-26.  2. Franz MJ, Boucher JL, Green-Pastors J, Powers MA. Evidence-Based Nutrition Practice Guidelines for Diabetes and Scope and Standards of Practice. J Am Diet Assoc. 2008;108(4 Suppl 1):S52-S58.  3. Lennon SL, DellaValle DM, Rodder SG, et al. 2015 Evidence Analysis Library Evidence-Based Nutrition Practice Guideline for the Management of Hypertension in Adults. J Acad Nutr Diet. 2017;117(9):1445-1458. 4. Bradley DW, Murphy G, Snetselaar LG, Myers EF, Qualls LG. The incremental value of medical nutrition therapy in weight management. Manag Care. 2013;22(1):40-45.  5. de Waal D, Heaslip E, Callas P. Medical nutrition therapy for chronic kidney disease improves biomarkers and slows time to dialysis. J Ren Nutr. 2016 Jan 1;26(1):1-9. 6. Centers for Medicare & Medicaid Services. Medicare National Coverage Determinations Manual. Baltimore, MD: CMS. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part3.pdf.  Accessed October 29, 2019. Disparities in Provision of MNT  Policy Brief Rural & Underserved Health Research Center  Page 7 7. Endevelt R, Baron-Epel O, Viner A, Heymann AD. Socioeconomic Status and Gender Affects Utilization of Medical Nutrition Therapy. Diabetes 2013;101(1):20-27.  8. Malon A, Deschamps V, Salanave B, et al. Compliance with French Nutrition and Health Program Recommendations Is Strongly Associated with Socioeconomic Characteristics in the General Adult Population. J Am Diet Assoc. 2010;110(6):848-856.  9. Centers for Medicare & Medicaid Services. Medicare Provider Utilization and Payment Data: Physician and Other Supplier. Baltimore, MD: CMS. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html.  Accessed March 15, 2019. 10.  U.S. Department of Agriculture, Economic Research Service. Rural-Urban Continuum Codes. Washington, DC: USDA; 2013. Available at: https://www.ers.usda.gov/data-products/rural-urban-continuumcodes/documentation.aspx.  Accessed March 17, 2019. 11. Centers for Medicare & Medicaid Services. Medicare Geographic Variation Public Use File. Baltimore, MD: CMS. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Geographic-Variation/GV_PUF.html. Accessed June 29, 2019.Centers for Medicare & Medicaid Services. Chronic Conditions. Baltimore, MD: CMS. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/CC_Main.html. Accessed October 10, 2019. 12. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2014;37(Supplement 1):S120-S143.         Contact Information Jeff Talbert, Deputy Director, Rural and Underserved Health Research Center   email: Jeff.talbert@uky.edu     website:  http://ruhrc.uky.edu   Suggested Citation Rhudy C, Shin E, Talbert J.  Rural/Urban Disparities in Utilization of Medical Nutrition Therapy to the Fee-for-Service Medicare Population.  Lexington, KY:  Rural and Underserved Health Research Center; 2020.  

Rural/Urban Disparities in Utilization of Medical Nutrition Therapy to the Fee-for-Service Medicare Population

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Rural/Urban Disparities in Utilization of Medical Nutrition Therapy to the Fee-for-Service Medicare Population

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