by Overview
A recent study published in JAMA estimated that more than six million people in the US have diet-sensitive conditions and activity limitations who could benefit from physician-tailored meals, a type of Food and Nutrition service that supports Medicine (MSF&N). These estimates also suggest that 1.6 million hospitalizations could be avoided and $13.6 billion saved annually if such meals were provided to these people. In recent years, growing evidence of the positive effects of nutrition assistance on health outcomes and costs has fueled policy change at both the federal and state levels—which, in turn, is creating new opportunities for health services organizations. and nurtured to work together to improve health through MSF&N services. This discussion highlights some of these opportunities.
What are MSF&N Services?
MSF&N’s services represent a spectrum of services that recognize and respond to the critical link between nutrition and health, including doctor-tailored meals and groceries, medically supported meals and groceries, producing prescriptions, and food pharmacies. The Food is Medicine Coalition, a national group of nonprofit MSF&N providers, represents these services along a spectrum that responds to the acuity of individual need. (See Figure 1.)
Figure 1. Spectrum of Food and Nutrition Interventions to Improve Health
Source: Food Is Medicine Coalition: Our Model
MSF&N services, by definition, are integrated into patient-centred models of care for the prevention, management and treatment of chronic illnesses and health conditions, and are distinct from the wider hunger safety net (eg, the Assistance Program Supplementary Nutrition or the National Nutrition Assistance Programme). School Lunch Programme).
Recent Health Policy Changes in Support of MSF&N Services
As the evidence base supporting the value of MSF&N services to health outcomes and costs has grown, new avenues of authority, funding, and integration into the health care delivery system have emerged.
Medicaid and Children’s Health Insurance Program (CHIP): Historically, certain MSF&N services were only available as part of the Medicaid Home and Community Services (HCBS) programs for individuals receiving long-term support services. In the 2010s, California, Massachusetts, and North Carolina became the first states to use Section 1115 Medicaid demonstration waivers to pay for MSF&N for individuals with certain complex chronic illnesses and other health conditions. Since then, dozens of other states have followed suit using 1115 waivers or Medicaid managed care “in lieu of services” (ILOS) authorities to fund MSF&N services in their Medicaid programs.1
In 2022, the Centers for Medicare and Medicaid Services (CMS) began formulating their policies on MSF&N, along with those on housing, culminating in the November 2023 Information Bulletin and accompanying framework, which lists these allowable services that following related to food and nutrition:
- Case management services relating to access to nutrition/food;
- nutrition counseling and teaching;
- Home delivered meals or pantry stocking;2
- Nutritional prescriptions (eg, fruit and vegetable recipes or protein boxes); and
- Grocery supply.
CMS’s guidance extends beyond the Section 1115 waiver to summarize other options for MSF&N Medicaid coverage, including options to cover such services through managed care plans (under the authority of ILOS), for populations with needs for services and supports long-term (through HCBS waivers), as part of the regular Medicaid benefits package (through state plan amendments), and for children (through CHIP Health Services Initiatives).
Medicare: In 2020, CMS issued guidance that defines and expands Special Supplemental Benefits for Chronic Persons (SSBCI) that Medicare Advantage plans, including Dual-Eligible Special Needs Plans (D-SNPs), can offer for outcomes improve the health of enrollees with chronic illnesses. Medicare Advantage plans are able to use SSBCI to offer meals, food, produce and transportation for grocery shopping. According to an analysis by Milliman, food, product and meal supports were among the most common SSBCI benefits offered by Medicare Advantage plans in 2023. Medicare Part A (traditional Medicare fee-for-service) does not reimburse meals delivered at home or otherwise. MSF&N services at this time.
Commercial and Market Programs: The Biden Administration has sought to prioritize nutrition integration in health care delivery across all payers. Commercial or market plans are offering doctor-tailored meals and/or grocery delivery to enrollees with specific diet-related health conditions across the country. For example, Geisinger Health’s Fresh Food Farmacy provides fresh, healthy food weekly to enrollees and their families when enrollees have A1C levels above 8.0 and are food insecure. Since its launch in 2016, enrollees participating in the Fresh Food Farming program have shown an average 2-point drop in HbA1c levels, lower weight, blood pressure, triglycerides, and cholesterol, and the plan found that medical costs dropped between $16,000 and $24,000 per participating roller.
Increased Opportunities for MSF&N Services
States: Recent CMS guidance provides a roadmap for states seeking to authorize, design, and launch MSF&N programs in their Medicaid systems. In the various states that have implemented MSF&N services, the Medicaid program has become one of the largest funders of those services. States play a critical role in defining which MSF&N services are covered, who is eligible to receive them, what standards providers must meet, and what data must be collected to evaluate outcomes. As more states deploy MSF&N services through Medicaid and document outcomes and lessons learned, other states are likely to follow suit.
Health Plans (Medicaid Managed Care Plans, Medicare Advantage, Private Insurers): Expanded reimbursement for MSF&N services enables plans to invest in popular, cost-effective interventions that can improve outcomes, reduce utilization, and improve the enrollee experience. As more states choose to add coverage for MSF&N in their Medicaid programs, many states are building the cost of service into plan rates and delegating the administration of services to plans, including identifying eligible individuals and hiring, contracting and supervising MSF&N supplier organizations, and tracking. enrollment utilization and health outcomes. Although adoption in the commercial market is still emerging, strong and thoughtful MSF&N programs can give commercial plans a competitive advantage and help keep costs down.
Health Care Providers: As MSF&N coverage has expanded, many health care providers are establishing partnerships with local food and nutrition organizations to reach patients with chronic diet-related diseases who are food insecure and who may benefit from services Screening, identification and transmission of MSF&N. As value-based payment arrangements continue to proliferate, providers who assume financial risk for their patients may view the integration of cost-effective interventions such as MSF&N services as an attractive proposition to support their patients and their costs and utilization. reduction.
MSF&N Organizations: As MSF&N services become more integrated into health care delivery, nutrition organizations have a new opportunity to sustain and scale their work. For example, the Food is Medicine Alliance has developed a voluntary national accreditation program for MSF&N providers. Grants and technical assistance (available through state Medicaid programs, health plans, and/or philanthropies) can help organizations establish new systems and expanded capabilities, such as contractual, administrative, data, and billing functions, necessary to support delivery of MSF&N services. . Larger and more experienced MSF&N organizations may have new opportunities under such programs to train other organizations and be compensated for that role. Organizations may also establish so-called “Community Care Hubs” that come together to share administrative functions and operational infrastructure and serve a more diverse range of populations. States differ in the extent to which they encourage the formation of such hubs.
Issues We Track
- How are state Medicaid programs:
- Authorizing funding of MSF&N services (eg, through Section 1115 waiver, ILOS waiver, HCBS)?
- Financially incentivize Medicaid plan and/or provider investment in MSF&N services (eg, reinvestment requirements, quality measures, incentive arrangements)?
- Building the costs of MSF&N services into Medicaid managed care rates?
- How do federal and state policymakers encourage Advantage Medicare plans and D-SNPs to provide MSF&N services through SSBCI?
- What support do health plans and health care providers need to effectively integrate MSF&N services into health care delivery?
- What infrastructure and capacity challenges do MSF&N providers face as they begin to bill and exchange data with health care organizations, and how are states, plans, and providers helping to address these challenges?
- What provider quality standards and oversight processes are states and plans adopting for MSF&N services?
- How do states and other payers evaluate the effectiveness of MSF&N services?
Conclusion
MSF&N’s services can help improve the lives and health outcomes of millions of Americans with diet-related health conditions. The increased coverage of MSF&N services, together with the growing recognition of food and nutrition as upstream drivers of health outcomes, represents an exciting focus on “whole person” care.
1 As of April 2024, State Medicaid programs authorized to pay for MSF&N services for specific populations include: Oregon, Washington, New Jersey, North Carolina, Massachusetts, New York, and California.
2 Of note, the CMS framework states that Section 1115 authorized nutrition support programs that provide three meals a day are limited to six months, renewable for additional six-month periods if the enrollee continues to meet the eligibility criteria. This limitation does not apply to programs that provide less than three meals per day.
