SummaryThe growing prevalence and disparities in chronic diseases necessitate that health plans address food insecurity to improve patient outcomes. The combination of increasing need for access to healthy food and changes in the health policy and insurance landscape create opportunities to address food insecurity through a variety of payers.
The links between food insecurity and poor health outcomes are described in a previous Avalere Insight and a myriad of peer-reviewed publications. Extensive evidence exists for a variety of food- and nutrition-focused interventions within the healthcare system to reduce food insecurity. Such interventions might include implementing consistent food insecurity screenings, addressing factors such as lack of housing or transportation that lead to food insecurity, or developing a database of community resources and referring patients as appropriate. A hierarchy of possible interventions is displayed in Figure 1.
Adapted from the Massachusetts Food is Medicine state plan.
However, significant barriers to effectively implementing these interventions in practice remain. These barriers may include lack of physician awareness and comfort in making referrals, lack of patient access to nutrition services and registered dietitians, and patients’ lack of personal resources to acquire healthy food in consistent and appropriate ways. Health plans may be hesitant to cover these services and interventions because of the long time period required to realize the return on their investment and the substantial time and effort required to coordinate services and ensure patient retention. The increasing transience of patients across health plans obscures the potential for direct connections between investments in prevention and reduced costs of care in the future.
A recent study estimated the potential cost-effectiveness of financial incentives for improving diet and health through Medicare and Medicaid and found that incentives for healthy foods led to substantial reductions in healthcare costs and improvements in health outcomes. These positive results could lead to substantial cost savings to Medicaid, Medicare, and commercial plans and provide the necessary evidence to healthcare administrators and insurers to invest in and support these programs.
Covering more than 60 million individuals and accounting for 15% (and rising) of our federal spending, Medicare serves some of the most complex patients in the US. Medicare Advantage (MA) plans have traditionally offered many supplemental benefits that are important for health outcomes but are not traditionally considered medical interventions by original Medicare plans. This is particularly important given that people who are elderly with disabilities may face significant barriers to securing food and would benefit from one or more interventions to maintain or improve their health.
Following the expansion of MA supplemental benefits through the Chronic Care Act of 2018, Avalere’s preliminary analyses suggest that MA benefit offerings have changed noticeably, with the percentage of plans covering meals increasing from 20% to 46%. However, the proportion of supplemental benefits targeting nutrition and wellness interventions only increased from 16% to 17%, indicating a remaining gap in opportunities to screen, assess, educate, and counsel at-risk patients. Further, substantial geographic variability in benefit coverage exists across the US (see Figure 2).
These trends indicate growing opportunities for providers to offer nutrition interventions and make referrals. Further, they suggest that more MA plans are able to offer these benefits and can stand to benefit significantly by doing so.
According to a 2018 survey, 32% of Medicaid beneficiaries usually purchase less-healthy food options than they otherwise would due to lack of money, compared to just 13% of non-Medicaid beneficiaries. State Medicaid programs and Medicaid plans are investing in food insecurity interventions due to their contribution to health outcomes for their at-risk populations. In 2017, Health Partners Plan implemented the first health plan-sponsored food-as-medicine program, and the CA state Medicaid program (Medi-Cal) introduced the first statewide medically tailored meal program in the US.
A 2019 study showed that participation in a medically tailored meal program appears to be associated with fewer hospital and skilled nursing admissions and less overall medical spending. As more state Medicaid programs seek to enhance their coverage by applying for section 1115 demonstration waivers, they may find more opportunities to introduce or expand food is medicine interventions to achieve such positive outcomes.
Commercial plans are also implementing innovative nutritional interventions that address food insecurity. Such interventions may include partnerships with community food banks, food pharmacies, government programs, and more that meet the needs of patients identified as food insecure. Plans may leverage existing statewide programs like the Supplemental Nutrition Assistance Program (SNAP); for example, Kaiser Permanente sponsors a “Food for Life” program that connects eligible members to CalFresh (which is California’s division of SNAP). Commercial plans might also invest in food banks to address this social need. In 2019, United Healthcare awarded a grant of $350,000 to the Jacobs & Cushman San Diego Food Bank to help address food insecurity and modernize its database. While these programs are very new and there are few national-level data on the number of such programs and their outcomes, they are certainly expanding in terms of geography, population, and scope.
Health plans are increasingly committing to tackling food insecurity and collaborating with community resources to expand the reach of their interventions. Avalere Health is also committed to this goal of improving patients’ health and quality of care through our history of working with and connecting a variety of key stakeholders during the transition to value-based care. We inform clients and the public about pertinent policy and marketplace changes based on our internal expertise and research. We also support existing and pilot research initiatives, including developing study designs, conducting robust data analyses, and formulating recommendations for stakeholders to support improvements in health and healthcare.
Through the Malnutrition Quality Improvement Initiative, we support healthcare systems around the country seeking to improve the quality of care provided to malnourished patients, including following hospital discharge and across transitions of care, by sharing best practices and providing research support—much of which includes addressing food insecurity as a key risk factor for readmissions. Last year, we worked with WellCare to analyze its MA Star Ratings program to highlight the impact of social determinants of health on health outcomes and highlight disparities. Our analysis linked information about these determinants to beneficiaries based on residence by 9-digit ZIP code, which enabled inclusion of more precise estimation of factors such as income and education level. We shared similar work accounting for SDOH in MA plans through risk adjustment at last year’s AcademyHealth conference. Ultimately, such findings will help to better estimate the association between these factors and quality outcomes and could inform development new risk adjustment methods that incorporate them and more fully account for patients’ needs.
We look forward to continuing and expanding this important work with more partners. For more information on how we assist our clients in evaluating their opportunities and risks in addressing food insecurity, please contact Kristi Mitchell and Natascha Dixon Edelin.
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