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In Reply: We thank Dr Hager and Ms Michael for reminding us that a physician's referral is required for Medicare to cover medical nutrition counseling. Although such consultations have the potential to simplify the nutritional recommendations contained in multiple CPGs, they also require additional health care visits for the patient. More problematic is the limited amount of evidence about the changing nutritional needs of older patients, which has led the American Diabetes Association CPG to state that "nutrition recommendations for older adults with diabetes must be extrapolated from what is known from the general population."¹

We look forward to the results of the current experiment in the United Kingdom linking a physician's pay to quality of care, described by Dr Roland,² and hope that the results will be applicable to older patients with multiple comorbid diseases. However, we are concerned that when performance indicators are calculated, these patients can be . . . [Full Text of this Article]

Cynthia M. Boyd, MD, MPH
cyboyd@jhmi.edu
Division of Geriatric Medicine and Gerontology
Department of Medicine
Johns Hopkins University School of Medicine
Baltimore, Md

Jonathan D. Darer, MD, MPH
Midatlantic Permanente Medical Group
Baltimore, Md

Chad Boult, MD, MPH, MBA
Roger C. Lipitz Center for Integrated Health Care
Johns Hopkins Bloomberg School of Public Health

Linda P. Fried, MD, MPH; Lisa Boult, MD, MPH, MA
Division of Geriatric Medicine and Gerontology
Department of Medicine
Johns Hopkins University School of Medicine

Albert W. Wu, MD, MPH
Johns Hopkins Bloomberg School of Public Health

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