Top Clin Nutr Vol. 18, No.3, pp. 199-203 © 2003 Lippincott Williams & Wilkins, Inc.

DIETETIC PRACTICE PROJECTS

A CCORDING to The American Dietetic Association (ADA) 2002 Environmental Scan for the registered dietitian (RD),

a greater need for services will come from new information about the role of diet in health care, new understanding of the diet’s contribution to chronic problems and the demands of an aging society. But there is nothing that automatically gives these opportunities to dietitians. They will have to shape their destiny individually and collectively catch up, keep up, and get ahead of the needs and issues facing the public. 1

The ADA’s most recent survey of members found that 10% of practitioners are self-employed (primarily RDs.) Of these, 6% of RDs and 2%of registered dietetic technicians indicate they are owners or partners in their practice. 2 These numbers have been increasing at a slow rate from 1991 (3.2%) to 1999 (3.5%)3. This means that there is a limited number of RDs who are available as private practice nutrition counselors.

In order to increase the visibility of RDs to the public, extra effort needs to be made to let people know how effective private practice nutritional counseling can be.

One of nutrition entrepreneur’s (NE’s) active members, Kathy King, wrote the “bible” for private practice in 1987 when private practice was unfamiliar to most practitioners and has continued it until 2003.4 Her latest edition of The Entrepreneurial Nutritionist includes not only consulting on the Web and marketing, but also ethical and legal concerns, selling supplements, and communications.

A private practice can be exciting, fulfilling, and financially rewarding. In an exhaustive investigation to date of compensation in the dietetics profession, a significant direct association was found between wage level and employment status (indicating self-employment is better). 2

Private practitioners need to have a strong, up-to-date knowledge base through participation in workshops, lectures, and meetings. Professional involvement helps a practitioner stay knowledgeable in the field, improve skills, and enhance the profession. In a recent study, a positive relationship was found between job satisfaction and markers of professional involvement 5. Dietitians should continue to learn the latest evidence-based research to provide quality nutrition services. It is important to be able to take research data and communicate it clearly and effectively to clients. Good counseling skills are required so that clients can adopt attainable goals and positive outlooks needed to accomplish them.

FINANCIAL ADVICE FOR PRACTICE

Starting a private practice can be inexpensive. You may need to work full time while seeing clients in the evening or weekends as your practice slowly builds a customer base. Once your client base grows, you may work part time until you have established a regular clientele. Typical start-up costs include the following:

· Rental space . Locations could be free space in your home converted to an office; or preferably a home with a separate entrance and reception area. For a small fee, you can negotiate rental of a part-time office adjoining another office, for example, with a physician, massage therapist, or fitness center. Allow a termination clause in your contract, usually 30 days,6 for expanding your business. Space is a large expense when opening an office in a business district with a full-time receptionist.

· Office Equipment. Initial costs are low (unlike that of a dental or doctor’s office). You will likely need a scale, computer, and furniture.

· Service costs. Telephone, fax and e-mail costs are minimal. When working from home, keep business expenses separate for tax purposes. Some rent and home expenses are tax deductible.

· Printing costs and supplies. Print cards, letterheads and brochures on your computer until the business is established. Thereafter, a graphic designer create a logo and professional stationary can be printed.

· Web site . Initial design costs are high; however, the costs of maintenance and changes are minimal. This component of the business should be established after income justifies the cost.

· Professional fees. Although a few RDs have lawyers, most do not need one. For an accountant or bookkeeper, choose one who works with small companies and has reasonable fees. They can help you with tax savings. Maintain accurate books and input your own income and expenses into a computer program helping to keep accounting costs down until the business is well established.

· Insurance fees . Loss of benefits and pension savings are the responsibility of the RD. These can make up a large part of expenses while establishing a business. For health insurance, an insurance broker can often get a reasonable price. Liability insurance is needed in the United States because of malpractice lawsuits in a litigious society . Healthcare Providers Service Organization (www.hpso.com) or Marsh (www.proliability.com ) can provide professional liability insurance for around $150 annually for a self-employed dietitian. Maintain good records of all clients to protect yourself. For the office, you will need general liability, another $150 annually, to cover burglary, fire, or personal accidents.

MARKETING YOUR PRACTICE

Marketing can take days, weeks, or even months before your practice starts, especially if you have a full-time job. A first step is to list with ADA’s Nutrition Network on www.eatright.org . Another beneficial investment is to join the NE’s dietetic practice group (DPG) at www.nutritionentrepreneurs.org. Through the DPG listserv, members can help with the marketing process, listen to others’ concerns, and share their experiences. Many times clients will move to another city and referrals from NE colleagues in other parts of the United States and the world are shared within the network. Family, friends, and health professionals also refer clients, and so let colleagues in clinical, administrative, and academic settings know about your private practice.

OTHER SUGGESTIONS

1. Prepare a 1-page introduction letter and brochure to send to physicians, other health professionals, fitness centers, massage therapists and psychologists in your area. The 1-page brochure should describe your practice, biography and fees, with a logo and professional photograph. Names and addresses of health professionals that can be found on the Internet could be added.

2. Attend functions, fund-raisers and networking events with business cards to hand out when requested.

3. Keep busy by writing, phoning, e-mailing and faxing potential contacts. If the first 6 months are slow, it is an opportune time to give free talks to the Rotary Club, the Chamber of Commerce, health fairs, etc.

4. Volunteer to serve on the local dietetics committee or DPG.

5. Return phone calls immediately. Returning calls within 4 hours has been most successful for me.

6. Design a Web site with a professional photograph, credentials, and experience. A website has become very important for dietitians in private practice because of frequent requests from potential clients.

FEES FOR SERVICES

What should you charge? Call local colleagues to determine professional fees to be charged for counseling sessions. I ask my clients to pay on the initial visit and tell them that before I book them. At the initial visit, I take their dietary, health and activity history and a 24-hour recall. They sign that the information is correct and also that they have read and understand the HIPAA regulations for disclosure of records. They leave with a meal and activity plan and goals. My initial session is 1 hour, followed by weekly 20-minute follow-up sessions where they keep a record of all foods eaten, their activity, and any questions or concerns. Some of my colleagues have told me they spend more time with their clients and see them less often: for example, a 1.5 hour initial consultation with 45-minute follow-up sessions once a month. You will need to see what works best for you.

SUPERBILLS OR STATEMENT OF ACCOUNT

Despite mergers, acquisitions and consolidations of insurance companies, 40% of the Standard & Poor’s top 25 health insurance companies provide reimbursement for medical nutrition therapy (MNT).7 Most dietitians give their clients a superbill that contains information about the professional, providing the service--name, address, registration and licensing/certification. The superbill also contains Medical Nutrition Therapy (MNT), including Current Procedural Terminology (CPT) codes such as diabetes mellitus (250) and disorders of lipid metabolism (272). Many codes require extensions to clarify the diagnosis,

International Classification of Diseases Ninth Revision (ICD-9) codes, 272.0 for pure hypercholesterolemia versus 272.2 for mixed hyperlipidemia (ww.eatright.org).

Most insurance policies will not reimburse clients who come for weight loss; often, this leads to many clients who become increasingly frustrated with their health insurance coverage.8 These clients should be informed of this problem before their first appointment. If clients have a chronic disease such as diabetes, the chance for reimbursement increases, depending on the health plan. Reimbursement strategies should improve because of consumer demand and greater attention being paid to evidence-based practice8. Two practitioners have designed camera-ready forms, letterheads, superbills, and all necessary materials to start your own business.9

BECOMING A PROVIDER

Becoming a MNT provider for a managed care organization (MCO) could increase potential client referrals and improve insurance coverage, however, it does take a great deal of time and does not guarantee payment. The MCO still decides which diagnoses and how many visits will be covered. Being persistent with calls and completing a lot of paperwork will lead to a higher reimbursement success. You may need to send 1 or 2 articles per mailing to demonstrate the effectiveness of MNT. You can also ask physician providers for MCOs to write letters in support of you becoming an MNT provider. Applications may be denied if several dietetics professionals are providers in the same market. The HCFA 1500 claim form is the accepted billing form for use with Medicare, Medicaid, and many insurers. More detailed information is available on the ADA’s website www.eatright.org .

REFERRALS

Where are you going to find clients? Expect most referrals to come from physicians and successful clients. Some referrals come from the Yellow Pages (a free listing with a business phone) or your website. When potential clients call, ask them on the phone what their concern is in case they have a rare chronic disease you need to review. Phone etiquette is important. Be sure your voicemail is in working order with a business-sounding message. Keep a separate line for your business and do not allow children, teenagers or inexperienced people answer the phone. Your speaking voice should sound confident and positive.

Once you have seen the client, send a thank you letter to the physician who referred the client. If the client came from another source, ask the client if you can send a report to let the physician know their patient is seeing you. Write a couple of paragraphs describing the reason for the visit, what was revealed during the dietary history, and what you recommended to the client. Sample letters are available from published books.4,9 When the clients return to the physician with a better weight or improved blood levels, the physician is frequently responsive to making future referrals. Even though professionals are ethically obligated to remain competent so that they can provide the best possible service to clients, customers and society,10 you may receive a referral for a disease state where you are not an expert, refer to a colleague who is.

As you reputation grows and the media starts contacting you, use this opportunity as free publicity. If they do not call, send press releases to television and radio stations, magazines and newspapers, stating your opinion on the “breaking” nutrition news. Writing articles for local newspapers is the easiest way to get your name known in your community.

A SUCCESSFUL IMAGE

Your image is reflected in your appearance, your attitude and your office. Decide what image you want to project: conservative, dynamic or sophisticated. When you see clients, be a role model. If they dress up for you, you need to dress up for them. Be sure your office is professional looking, yet warm and friendly.

Registered dietitians have an important role to play in lowering the incidence of obesity and chronic diseases. We are the nutrition experts. One means of exhibiting our nutritional expertise is by running a successful private practice. Using astute business skills, reimbursement expertise, and evidence-based research in helping clients will result in higher visibility and increased recognition of the benefits of MNT.

REFERENCES

1. Escott-Stump S, Jarratt J, Mahaffie JB. Key trends affecting the dietetics profession and the American Dietetic Association. J Am Diet Assoc. 2002;102(12):S1819-S1839.

2. An executive summary of the ADA 2002 Dietetics Compensation & Benefits Survey. J Am Diet Assoc. 2003;103(2):243-255.

3. Bryk JA. Report on the 1999 membership database of the American Dietetic Association. J Am Diet Assoc. 2001(101);8:947-953.

4. King K. The Entrepreneurial Nutritionist. 3rd ed. 2003. Lake Dallas, Tex: Helm Publishing. Available at: http://www.helmpublishing.com
5. Mortensen JK, Nyland NK, Fullmer S, Effett DL. Professional involvement is associated with increased job satisfaction among dietitians. J Am Diet Assoc. 2002;102(10):1452-1454.
6. McCaffree J. Contract basics: what a dietitian should know. J Am Diet Assoc. 2003;103(4):428-429.
7. Baraboski C. Insurance companies are reimbursing for medical nutrition therapy. J Am Diet Assoc. 2000;100(12): 1530-1532.
8. Fitzner K, Myers EF, Caputo N, Michael P. Are health plans changing their views on nutrition service coverage? J Am Diet Assoc. 2003;103(2):157-161.
9. Litt A, Berger MF. Be your own boss...the basics of starting a private practice. 2003; LITT1007@aol.com
10. Gates G. Ethics opinion: dietetics professionals are ethically obligated to maintain personal competence in practice. J Am Diet Assoc 2003;103(5):633-635.