Food-Is-Medicine Landscape & Health-Related Social Needs (HRSN)

Food Is Medicine Landscape

In recent years, there has been a growing recognition of the pivotal role that food plays in health outcomes. Food-focused health interventions, often referred to as food is medicine (FIM), have emerged as essential components of public health initiatives and healthcare delivery systems. From medically tailored meals to culinary medicine programs, these interventions aim not only to improve nutrition but also to address underlying health disparities and promote overall wellbeing. In this comprehensive overview, we delve into the multifaceted landscape of FIM interventions, exploring their significance, recent developments, implementation challenges, and future prospects.

Understanding Food Is Medicine Interventions

The spectrum of FIM interventions encompasses a range of approaches aimed at leveraging food as a therapeutic tool to improve health outcomes. At its core, FIM seeks to address the complex interplay between diet, health, and social determinants. Key interventions include:

1. Medically Tailored Meals (MTMs): These meals are specifically designed to meet the unique nutritional needs of individuals with chronic illnesses. MTMs are often prescribed by healthcare providers and tailored to address specific health conditions, dietary restrictions, and cultural preferences.
2. Healthy Food Packages and Groceries: Providing access to nutritious food is fundamental to FIM interventions. Programs that offer healthy food packages or groceries aim to alleviate food insecurity and promote healthy eating habits among vulnerable populations.
3. Nutrition Referrals or Vouchers: By connecting individuals to nutrition services and resources, such as dietitians and community food programs, FIM interventions seek to empower individuals to make informed dietary choices and improve their overall health.
4. Prescriptions for Nutritious Groceries: In some cases, healthcare providers may prescribe nutritious groceries or produce as part of a comprehensive treatment plan. These prescriptions aim to address food insecurity and support individuals in maintaining a healthy diet.
5. Culinary Medicine and Teaching Programs: Culinary medicine programs integrate nutrition education with cooking skills, empowering individuals to translate dietary recommendations into practical, everyday meals. These programs often focus on teaching cooking techniques, meal planning, and healthy food preparation methods.

While the primary goal of FIM interventions is to improve health outcomes through nutrition, they also play a crucial role in addressing social determinants of health (SDOH). By addressing factors such as food insecurity, access to healthy food options, and cultural preferences, FIM interventions strive to reduce health disparities and promote health equity.

Recent Developments and Policy Initiatives

In recent years, there has been a concerted effort at the national level to elevate the importance of FIM interventions as part of broader public health and healthcare initiatives. The Biden-Harris Administration, in particular, has made addressing food insecurity and promoting healthy eating a priority. Some key developments and policy initiatives include:

• 2022 Biden-Harris Administration National Strategy On Hunger, Nutrition, And Health: This strategy outlined a comprehensive approach to end hunger and increase healthy eating in America, emphasizing the importance of FIM interventions in achieving these goals.
• White House Challenge to End Hunger and Build Healthy Communities: This initiative inspired stakeholder organizations across the country to make significant commitments to advance the goal of ending hunger and promoting healthy eating.
• 2023 U.S. Playbook To Address Social Determinants Of Health: This playbook outlined federal agencies' actions to achieve equitable health outcomes by addressing SDOH, including the use of various FIM interventions to improve food and nutrition security.

These initiatives underscore the growing recognition of the role of FIM interventions in addressing food insecurity, improving health outcomes, and promoting health equity. By mobilizing resources and fostering collaboration across sectors, policymakers aim to expand access to FIM interventions and reduce disparities in access to healthy food options.

Challenges and Implementation Considerations

While FIM interventions hold promise for improving health outcomes and reducing health disparities, they also face significant challenges in implementation. Some key challenges include:

• Access and Affordability: Access to FIM interventions, particularly for underserved populations, remains a significant barrier. Cost can also be a limiting factor, as many FIM interventions require additional resources and infrastructure to implement effectively.
• Health Equity: Addressing health disparities and promoting health equity are central to the mission of FIM interventions. However, disparities in access to healthcare, nutritious food, and social resources continue to persist, posing challenges to achieving equitable outcomes.
• Integration into Healthcare Systems: Integrating FIM interventions into existing healthcare systems requires coordination across multiple stakeholders, including healthcare providers, payers, community organizations, and policymakers. Building partnerships and leveraging existing resources are essential for successful implementation.
• Evidence Base and Evaluation: While there is growing evidence supporting the effectiveness of certain FIM interventions, more research is needed to establish their impact on health outcomes, cost-effectiveness, and sustainability. Rigorous evaluation and data collection are essential for informing policy and practice.

Despite these challenges, there is a growing momentum behind FIM interventions, driven by increasing recognition of their potential to improve health outcomes, reduce healthcare costs, and promote health equity. By addressing barriers to access, fostering collaboration, and investing in research and evaluation, stakeholders can work together to advance the field of FIM and improve the health and wellbeing of communities across the United States.

Coverage of Health-Related Social Needs (HRSN) Services in Medicaid and the Children’s Health Insurance Program (CHIP)

In November 2023, the Centers for Medicare & Medicaid Services (CMS) issued the Medicaid and CHIP HRSN Framework to provide guidance for states to structure programs that address nutrition insecurity through various FIM interventions, including culinary medicine, for high-need enrollees. CMS has thus far approved seven section 1115 demonstration waivers that reflect FIM-related interventions in California, Oregon, Massachusetts, Arizona, Arkansas, New Jersey, and Washington.

This framework lists HRSN services and supports considered allowable under specific Medicaid and Children’s Health Insurance Program (CHIP) authorities and provides a discussion of the relevant considerations for each authority. The allowable HRSN services and supports enumerated here are based on robust evidence of strengthening coverage and improving downstream health outcomes, cost, and/or equity. All interventions must be evidence-based and medically appropriate for the population of focus based on clinical and social risk factors.

These services will be the choice of the enrollee; enrollees can opt out anytime; and provision of these services does not absolve the state or managed care plan of its responsibility to provide coverage for other medically necessary services. Medicaid-covered HRSN services and supports must not supplant the work or funding of another federal or state non-Medicaid agency and must be integrated with existing social services and housing assistance. Under Medicaid authorities, CMS will not approve federal financial participation payments for the costs of room and board outside of specifically enumerated care or housing transitions, nor may CMS approve services that include room (i.e., rent and utility assistance) and board (i.e., meals or nutrition prescriptions) beyond durations specified below. There are no time limitations to other services, unless otherwise specified. Under no circumstances will a state or managed care plan be permitted to condition Medicaid or CHIP coverage, or coverage of any benefit or service, on receipt of HRSN services. There are additional beneficiary protections, guardrails, and requirements for programming under specific authorities.

Related Healthcare Requirements and Incentives

The US healthcare system has faced many new requirements and incentives to address HRSNs and advance health equity in recent years. Using FIM as a healthcare intervention aligns with and indeed supports alignment with these changes. For example, The Joint Commission imposed new healthcare equity standards, beginning in 2023, for its accreditation programs. These include tactics such as writing action plans to advance health equity, which could include delivering FIM interventions to underserved and/or high-risk patient populations. Also, beginning in 2024, CMS has mandated that hospitals include in their reporting through the Hospital Inpatient Quality Reporting Program two new measures related to social needs, Screening for Social Drivers of Health and Screen Positive Rate for Social Drivers of Health. Identification of food insecurity (or other drivers) may be an eligibility criterion for receiving a FIM intervention; also, hospitals can use findings from such screenings to direct appropriate interventions (in coordination with community partners, as needed) to meet patients’ food and nutrition needs.

Emerging Opportunities for Revenue

Payers are also increasingly interested in covering FIM benefits for patients, which can provide more business opportunities for FIM vendors. Motivating factors may include the ability to improve beneficiary enrollment and engagement with benefits, reduce attrition, reduce unnecessary healthcare utilization and costs, and other positive changes. Notably, coverage by private payers is not consistent across markets and is currently more limited than coverage by public plans.

Medicare

Since 2018, the Centers for Medicare and Medicaid Services (CMS) has allowed Medicare Advantage (MA) plans to offer food benefits under Special Supplemental Benefits for the Chronically Ill. In 2020, CMS enabled MA supplemental benefits to extend beyond MTMs and cover food and other supports for chronically ill patients. At that time, 101 plans offered healthy food-related benefits. In 2024, this will expand to 1,475 plans. And while fewer plans will cover MTMs in 2024, many more are covering healthy food prescriptions.

Alternative payment models being tested by the CMS Innovation Center may also cover these benefits. One example that incorporates FIM-related benefits is the MA Value-Based Insurance Design (VBID) model, which tests a broad array of service delivery and/or payment approaches. It was recently extended through 2030 and modified to more fully address HRSNs (as well as meet other goals)—including requiring participating organizations to offer supplemental benefits to address HRNS related to food (among other areas). Plans can cover FIM interventions such as MTMs and provide rewards to incentivize utilization of high-value services by nutrition professionals—and do so based on health condition, socioeconomic status, or both factors. Other examples of models that can incorporate FIM interventions to advance health equity are the All-Payer Health Equity Approaches and Development model, newly announced in 2023, and Accountable Care Organization Realizing Equity, Access, and Community Health model for traditional Medicare beneficiaries that began in 2023.

Medicaid

States have a few mechanisms for providing FIM interventions through Medicaid. These may include covering through in lieu of services or providing value-added benefits in Medicaid managed care or section 1115 or 1915 demonstration waivers to pilot test FIM interventions. In November 2023, CMS issued the Medicaid and CHIP HRSN Framework to provide guidance for states to structure programs that address nutrition insecurity through various FIM interventions, including culinary medicine, for high-need enrollees. CMS has thus far approved seven section 1115 demonstration waivers that reflect FIM-related interventions in California, Oregon, Massachusetts, Arizona, Arkansas, New Jersey, and Washington.

Conclusion

As the healthcare landscape continues to evolve, the integration of FIM interventions into healthcare delivery systems presents an opportunity to address the root causes of poor health outcomes and promote health equity. By leveraging the power of food to prevent and manage chronic diseases, support recovery and healing, and address social determinants of health, FIM interventions offer a holistic approach to healthcare that prioritizes the wellbeing of individuals and communities. As policymakers, healthcare providers, payers, and community organizations collaborate to expand access to FIM interventions, we have the potential to transform healthcare delivery and improve health outcomes for all. Through continued investment, innovation, and commitment to health equity, we can harness the power of food to build healthier, more resilient communities for generations to come.

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