Decades of research show that while poor dietary quality is linked with an increased risk of mortality and many chronic conditions, following a healthy dietary pattern can help to reduce that risk and change a patient’s trajectory. Studies also show that addressing food insecurity and malnutrition leads to better health outcomes. Healthcare stakeholders are taking steps to address these issues from a variety of perspectives, with strategies ranging from educating patients about healthy cooking, to meal delivery, to increasing referrals to dietitians. Recent regulatory changes present additional opportunities for providers and payers to intervene in both clinical and community settings to improve dietary quality, with the goals of prevention and improved disease management for their patients and members. While some food industry stakeholders have begun to integrate their operations into the healthcare system, opportunities remain for further collaboration to improve outcomes and quality of life for their patients, customers, and members.

Current Nutrition and Food Insecurity Landscape Across High-Risk Populations

Poor diet and limited access to nutrient-dense foods is closely tied to negative health outcomes, including chronic diseases such as cardiovascular and kidney disease. However, the COVID-19 pandemic has brought greater attention to the connection between nutritional status and dietary intake with susceptibility and resilience to infectious disease. Due to factors such as limited income and older age, Medicare and Medicaid beneficiaries in particular may be at higher risk of malnutrition and food insecurity than the general population.

Many high-risk beneficiaries face unmet needs in accessing healthy, culturally sensitive foods on an ongoing basis. Medicare Advantage (MA) plans have traditionally covered meals for those recently discharged from the hospital and those who have chronic conditions such as diabetes or chronic kidney disease. However, members with heart disease, cancer, gastrointestinal disease, and malnutrition often do not have access to these same benefits. Further, some beneficiaries may need longer or more intensive dietary interventions to improve their health status. Finally, clinicians—including dietitians—reported a gap of nutritional knowledge among providers when connecting patients with food and nutrition benefits covered under their health plans.

Recent Opportunities for Increased Food and Nutrition Interventions and Reimbursement

The COVID-19 pandemic has also increased awareness of health disparities and emphasized the importance of addressing poor diet and food access and related issues as 1 component of mitigating these disparities. This focus—combined with additional regulatory flexibility, increased supplemental benefits funds for some plans, and growing interest among local and national leaders in addressing social determinants of health—has translated to heightened interest among health plans and systems in offering nutrition-related benefits. In addition, health plans can market the offering of such benefits as a differentiator for their member retention and enrollment growth.  In 2022, more $0 premium MA plans will offer non-medical benefits, such as transportation to grocery stores, nutrition education and counseling, and meal services. Specifically, compared to 2021, the number of $0 premium MA plans offering meals as a supplemental benefit will increase from 30% to 40% and those offering a nutritional benefit will more than double.

Additionally, federal programming and legislative efforts focused on nutrition interventions continue to gain traction. In Medicare Fee-For-Service, the National Diabetes Prevention Program model (which has existed for more than a decade) was expanded in 2018, and there have been national programming and legislative efforts to study the efficacy of providing medically-tailored meals and to expand Medicare benefits to cover medical nutrition therapy.

Another recent opportunity arises from the inclusion of an improvement activity focused on screening and intervening for food insecurity and malnutrition in the Merit-based Incentive Payment System Quality Payment Program though the CY 2022 Medicare Physician Fee Schedule. In this final fee schedule, the Centers for Medicare & Medicaid Services included an Avalere-submitted, malnutrition-focused improvement activity, which further incentivizes health system stakeholders to screen and intervene or refer members to needed food resources in their community. This presents a novel opportunity for the food industry to partner with healthcare providers to address similar gaps in food access and improve dietary intake. This activity arose from Avalere’s history of collaboration on the Malnutrition Quality Improvement Initiative. We have also collaborated with multistakeholder partners in efforts to advance health equity and sustainable programming at the local level as part of a Robert Wood Johnson Foundation grant.

Health System-Based Interventions That Can Meet Food and Nutrition Needs

Different stakeholders in the healthcare system can engage to address nutritional needs among high-risk populations in many ways, which include:

• Delivery of culturally relevant medically tailored meals, grocery boxes, or meal kits: patients with chronic conditions—and especially those in food deserts or unable to travel to grocery stores—could benefit greatly from condition-specific, nutrient-dense foods. These food benefits should be tailored to different cultural preferences to encourage uptake and adherence.
• Grocery benefits: offering a grocery benefit, such as a prepaid gift card, incentivizes purchases of approved foods (such as produce and pantry staples) to encourage healthy purchases and cooking habits.
• Supplemental nutrition education and counseling services: offering nutrition education and counseling through dietitians can enhance nutrition literacy and support healthy eating; further, combining education and grocery offerings may help members improve individuals’ eating habits.

Key Takeaways and Conclusion

Improving nutrition-related health outcomes through interventions spanning food deliveries and grocery incentives to education and counseling can assist in the mitigation of growing healthcare costs and health disparities. Recent flexibilities for payment and benefit design are enabling more innovation for food and nutrition, and increased collaboration among a broad set of stakeholders can further improve the uptake of these benefits and achievement of the intended nutrition goals and health improvement. Engaging with community partners and incorporating patients’ perspectives is vital for providing appropriate meals, food, and related services to those with chronic conditions. Additionally, community partners can facilitate referrals for patients identified as at risk for food insecurity or poor nutritional status. Addressing and closing the knowledge gap in nutrition and behavior among physicians, improving coordination with care managers and other healthcare staff, and streamlining processes for coverage and reimbursement at the institution and policy levels can all facilitate better identification and utilization of different types of food and nutrition benefits.

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