Transcription:

Christina: Hello and welcome to another episode of Avalere Health Essential Voice. My name is Christina Badaracco and I’m a research scientist and Registered Dietitian (RD) in the Center for Healthcare Transformation here at Avalere. I’m joined today by Kim Madsen, a fellow Registered Dietitian who’s the Director of Nutrition Services at Project Open Hand in the San Francisco Bay Area, and David Waters, CEO of Community Servings in the Greater Boston area.

Project Open Hand and Community Servings are nutrition service organizations that serve medically tailored meals (MTM), provide nutrition education and food service job training, and advocate for public policy that supports increased access to food and nutrition care for medically complex individuals.

In today’s episode, we will discuss the growing role of MTM in addressing food insecurity and poor health for community-dwelling and medically complex individuals, including how they relate to health outcomes and healthcare costs, and increasing opportunities to expand reach through health insurance plans such as Medicare Advantage.

To start off, can you please define MTM and briefly describe how and where they’re made?

David: Thank you, Christina, and thank you to Avalere for including Community Servings. I know Kim feels the same way.

We define MTM as meals that are delivered to individuals living with severe illness through a referral from a medical professional or healthcare plan. Meal plans are tailored to the medical needs of the recipient by a Registered Dietitian/nutritionist, and are designed to improve health outcomes, lower cost of care, and increase patient satisfaction.

Christina: Great, thank you. So, we’ve seen increasing attention in the healthcare sector on addressing social determinants of health (SDOH), with the COVID-19 pandemic highlighting persistent vulnerabilities among socioeconomically vulnerable individuals. For medically complex patients in particular, food insecurity can exacerbate disease complications or impair their ability to adhere to chronic disease management regimens.

Thus far, studies have shown that MTM are associated with fewer hospital admissions and less overall spending, as well as improved adherence to retroviral therapy in patients living with HIV, and improved perceived self-management in patients with diabetes.

David, what research has Community Servings conducted in this field, and what are the current gaps in research related to MTM? What future areas of research are needed to build on the existing evidence base?

David: Community Servings has led 3 research studies with Dr. Seth Berkowitz of UNC School of Medicine on the clinical and economic benefits of MTM. These are really exciting studies.

We began with a pilot clinical trial testing the impact of MTM on 44 individuals with advanced diabetes and food insecurity. The study, published in the Journal of General Internal Medicine in November of 2018, showed a 31% improvement in healthy eating habits as measured by the healthy eating index after 12 weeks of receiving our meals. Meal recipients experienced less hypoglycemia, reductions in food insecurity, and improvements in mental health and wellbeing.

This summer, Dr. Berkowitz received an RL1 grant from National Institutes of Health (NIH) to expand the pilot research with Community Servings to test the impact of MTM on 100 individuals receiving MTM versus 100 individuals receiving the usual care and a grocery gift card. This NIH support is exciting and represents where we hope MTM research will head. When the NIH released its 2020-2030 Strategic Plan for Nutrition Research, it included food as medicine research as one of its 4 key strategic questions.

The second study we did with Dr. Berkowitz, published in Health Affairs in 2018, examined the claims data of dual-eligible individuals receiving our meals through health insurance plans. The study found that meal recipients had an average monthly reduction in healthcare costs of 16% versus a match control group, and these are very expensive patients. Meal recipients had significant reductions in hospitalizations, emergency room visits, and ambulance usage.

The third study was an expansion of the second and was published in JAMA Internal Medicine in April 2019 looking again at insurance claims data, but this time for 807 MTM recipients over a period of 4 years. This has been the largest study of its kind to date. Results again showed a 16% reduction in monthly medical costs, as well as significant reductions in hospital and skilled nursing facility admissions.

Finally, we’re just starting a partnership again with Dr. Berkowitz as well as Dariush Mozaffarian of the Tufts Friedman School of Nutrition and our partners, in a unique Medicaid demonstration project that allows for the reimbursement of MTM. We’re evaluating the impact of MTM on this program. I think the results of this are going to be groundbreaking and so important for proving the impact of medical meals on various diagnoses and cost factors.

Christina: So as founding partners of the Food Is Medicine Coalition, both of your organizations were instrumental in the formation of a bipartisan Food Is Medicine Working Group in the House of Representatives, which introduced a bill to establish a Medicare pilot demonstration for home delivery of MTM earlier this year.

What additional actions at the federal level do you think are important to improve food security and health for medically complex individuals?

David: From my perspective, first and foremost, we’d like to see the legislation you’re referring to, the Medically Tailored Home Delivered Meal Demonstration Pilot Act of 2020, passed. This bill would establish a Medicare pilot program to address the critical link between diet, chronic illness, and the health of older adults. This proposal will ensure that medically vulnerable seniors get access to lifesaving MTM in their home while providing the outcomes data we need to build a more resilient and cost-effective healthcare system. Both goals are even more critical during the pandemic as we endeavor to keep the elderly, especially those living with severe and chronic illnesses, healthy and at home.

In addition, we want to see MTM covered through Medicaid rather than the current patchwork approach in which some states allow for direct billing to Medicaid, and others, including Massachusetts, allow coverage through time-limited demonstration projects and waivers or managed care plans. Ultimately, we view this as an issue of health equity and justice. People coping with poverty and illness should receive MTM as a fundamental right to medical care, regardless of where they live.

Insofar as other federal actions beyond direct funding or coverage of MTM, promoting research on MTMs, as the NIH has tried to do, will also be critical.

Christina: Thank you, David. I would also add that over the past couple of years, we’ve seen regulatory action at the federal level to expand coverage of supplemental benefits that are not considered primarily health related, such as MTM, to improve outcomes for chronically ill patients under Medicare Advantage plans. We’ve also seen state Medicaid agencies engage in innovative partnerships with MTM and nutrition service organizations.

Kim, can you tell us more about the MTM pilot program that Medi-Cal launched in partnership with Project Open Hand in 2018?

Kim: Sure, so California launched a first-of-its-kind medical nutrition pilot program as a result of a California Senate bill signed into law in mid-2017. This is now more commonly referred to as the Statewide MTM Pilot.

This bill provides an amazing $6 million of funding over a 3-year period aimed at improving health outcomes and reducing healthcare costs for Medi-Cal beneficiaries with the diagnosis of congestive heart failure (CHF), which is very costly due to the high utilization of healthcare services. So, this pilot is essentially designed as a CHF disease treatment program for those who are not only at high risk for hospital readmissions, but worsening health outcomes as well.

This Medi-Cal medical benefit is being provided by 6 community-based nonprofit organizations in 7 counties throughout California. These 6 organizations also comprise the California Food Is Medicine Coalition or CalFIMC. This has been a highly collaborative project. The participants in this MTM pilot receive home delivery of up to 100% of their daily nutritional needs for 12 consecutive weeks. In conjunction with this MTM program, participants receive 4 medical nutrition therapy sessions with a Registered Dietitian. These sessions consist of individualized nutrition counseling and education that was collaboratively developed by the RDNs from the CalFIMC agencies.

What I really like is that we designed the RDN intervention to include 2 home visits. We have found visiting the home allows for the observation of the living space, engagement of other household members, and opportunity to see what is in the kitchen, such as food, cooking equipment, and storage.

For example, the dietitian frequently provides education on fluid restriction, including instruction on how to measure daily fluid intake to control some severe symptoms of CHF. Often, participants do not have typical measuring utensils. Being in their environment, we can teach with what is available to the client, so it might be a coffee mug or a drinking glass or even a Coke can.

The participants in this pilot program have proven to be a challenging segment of our population to engage due to the myriad social challenges typically encountered by chronically ill low-income individuals. The adjunct of the RD intervention with the MTM provides that added touch point to assist participants in navigating difficult barriers to access safe and adequate food.

Christina: So, to follow the previous question, how have you seen the COVID-19 pandemic affect the administration of this program and for other populations that you serve? What changes has your organization made to respond to COVID-19?

Kim: It turned out that the MTM pilot was somewhat COVID-resistant or at least COVID-compatible as designed, but we still had to adapt to COVID guidelines. For example, COVID restrictions required Project Open Hand and our sister agencies to shift our in-home nutrition visits to phone and video visits to limit exposure for our clients because their health and safety are obviously paramount during these difficult times.

Although “shelter in place” has made us adapt the way we operate, we have experienced improved engagement with our “shelter in place” clients because they are home and available for nutrition sessions and to receive food and meal deliveries.

Recruitment for Project Open Hand services has steadily risen over the past several months since COVID restrictions began. Anecdotally, we feel referring partners have the MTM pilot program more top-of-mind due to the concern for access to food and medically appropriate nutrition for those with complex medical conditions. Much of the administration of the program has remained the same since it was designed as a home delivery program, but we haven’t been able to continue with the intervention.

Christina: Thank you, Kim. So, to learn more about these issues and what Avalere and leading stakeholders throughout healthcare are doing to address them, we recommend searching on Avalere.com for nutrition or food insecurity to see previous articles we’ve written and podcasts we hosted about these topics. I’ll mention an insight published earlier this year titled “Payer Issues Part Two: Health Plans Interventions to Address Food Insecurity.” Audience members can also find our email addresses by visiting Avalere.com/podcasts.

David and Kim, do you have any resources to recommend to our audience?

David: Yes, I would recommend 2. The first is the Community Servings website, which is www.servings.org. It has an excellent research page that references, with links, each of the research studies I mentioned, as well as a whitepaper that summarizes them.

In addition, our national association, the Food Is Medicine Coalition, or FIMC, is at FIMCoalition.org. It’s a great resource for reviewing policy opportunities and fact sheets, as well as overviews of MTM research that’s been conducted across the country.

There are also great resources available on the Food Is Medicine Massachusetts Coalition website, our state coalition, which is FoodIsMedicineMA.org.

Kim: I would echo David’s suggestion for the Food Is Medicine Coalition and would also add the California Food Is Medicine Coalition for California-specific work in this area (CalFIMC.org).

For additional policy information, you can search for food insecurity or food is medicine on the Center for Health Law and Policy Innovation (CHLPI.org). UCSF’s SIREN is a great source of information on the intersection of healthcare and food insecurity (sirenetwork.ucsf.edu).

Christina: Thank you both so much, Kim and David, for joining us today. Your insights are invaluable to our listeners and highlight the important role of nutrition interventions in treating medically complex patients. Thank you all for joining us and please stay tuned for more episodes focused on nutrition and social determinants of health. If you’d like to learn more, please visit us at Avalere.com.