New York Times News Service
By ROBERT PEAR

WASHINGTON, Dec. 31 — Starting on Tuesday (January 1, 2002), Medicare will recognize and pay for two services badly needed but little used by the elderly, nutrition therapy and pain management.

The nutrition benefits will be available to more than seven million people who have diabetes or kidney disease, helping them choose the kinds of foods that can control or treat their illnesses. Based on the experiences of this group, the secretary of health and human services is supposed to advise Congress whether similar benefits should be made available to other people on Medicare, providing ways to reduce high blood pressure or to lower cholesterol, for example.

Cindy Moore, director of nutrition therapy at the Cleveland Clinic Foundation and a spokeswoman for the American Dietetic Association, said: "There is enormous potential for medical nutrition therapy to save taxpayers dollars and improve the quality of life for patients. Diet has a major role in the management of diabetes and can help reduce the risk of getting many other chronic diseases of aging like heart disease, osteoporosis and cancer."

Doctors said Medicare's decision to recognize pain management as a specialty would help many patients with cancer, sickle cell disease and other conditions that cause chronic pain.

Medicare's coverage decisions often influence private insurers. Dietitians and doctors who specialize in pain medicine said they hoped private insurers would follow the example set by Medicare in recognizing the value of their services.

For years, dietitians have sought Medicare coverage of nutrition counseling and therapy. Congress, as part of a law passed in December 2000, agreed to provide the benefits after receiving a report from the National Academy of Sciences that said such coverage was likely to save money for Medicare and benefit patients.

Nutrition therapy is supposed to mesh with other types of care that a patient receives. The patient must have a referral from a treating physician — the primary care doctor or specialist coordinating the patient's care. The government will then pay for a registered dietitian or other nutrition professional to assess the patient's needs, provide counseling and develop a treatment plan to improve the patient's diet.

The Department of Health and Human Services estimates that Medicare will spend $270 million on nutrition therapy benefits in the first five years. It has not estimated the savings that might result from a reduction in hospital admissions, surgery and other costs.

Ms. Moore said a dietitian might charge $100 to $130 for 45 minutes to an hour of counseling. A visit to a doctor could cost three to five times as much, and a surgical procedure would cost far more.

In recent years, Medicare has slowly expanded to encompass a small but growing number of preventive health care services. Nutrition therapy illustrates that trend.

On Tuesday, the government will also establish a reimbursement code allowing doctors to identify themselves as specialists in pain management. This is a major accomplishment for the field of pain medicine and will make it easier for doctors to bill Medicare for these services.

Kimberly A. Kutska, a spokeswoman for the American Academy of Pain Medicine, said the new billing code would help patients and doctors.

"Often," Ms. Kutska said, "specialists in pain medicine don't get properly reimbursed for the procedures because they don't have their own specialty code."

Many expert studies have concluded that patients are not being adequately treated for chronic pain. The Medicare reimbursement code will encourage doctors to provide such treatment to patients with cancer, arthritis, sickle cell anemia, AIDS and other diseases that cause severe pain.

Dr. Albert L. Ray, president of the American Academy of Pain Medicine, said, "With the new code, it will be far easier for patients to identify and locate doctors who specialize in pain medicine."

Such doctors may now be listed as neurologists, neurosurgeons, anesthesiologists, psychiatrists or specialists in rehabilitation medicine.

Medicare provides health insurance for 40 million people who are elderly or disabled. About 6.3 million people ages 65 or older — more than 18 percent of the elderly — have diabetes and could qualify for nutrition therapy, according to government data.

In addition, Josef Coresh, an epidemiologist at Johns Hopkins University, said that eight million people had lost at least half of their kidney function and that six million of them were 65 or older. Those with advanced kidney disease may have priority in receiving nutrition therapy. About 330,000 elderly people have lost at least three-fourths of their kidney function and are likely to have the most severe nutritional deficiencies, Dr. Coresh said.

"People with kidney disease become nauseous, lose their appetite, have a higher risk of malnutrition and have poorer metabolism of the food they do eat," he said. "So they should be able to benefit from nutrition therapy."

Another change in Medicare that takes effect on Tuesday will limit the ability of beneficiaries to move into and out of health maintenance organizations. They have been able to drop out of H.M.O.'s or switch to other health plans once a month. But in the coming year, they will be able to make only one change, in the first six months of the year. In the annual open enrollment period in November, they will be able to make
a new choice for 2003.

Organizations representing Medicare beneficiaries and H.M.O.'s have lobbied Congress to repeal the law that locks patients into health plans, but Congress has not taken action.

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