How healthcare payers can expand nutrition support for the food insecure

Combating food insecurity is a social and economic challenge. That much became clear during the past year, when the COVID-19 pandemic skyrocketed the number of people experiencing food insecurity in the United States. Feeding America estimates that 45 million Americans (one in seven) may have experienced food insecurity in 2020,1 a nearly 30 percent increase from 2019 despite the expansion of social support programs during the pandemic.

Food insecurity is also a medical issue—one with serious implications for people with diseases and medical conditions affected by diet. While access to high-quality nutrition boosts health and well-being, poor nutrition is directly related to poor health. According to previous McKinsey research, people who are food insecure are more than twice as likely as people with no unmet social needs to report poor physical or mental health and to make multiple visits to the emergency room. They are also twice as likely to report an inpatient hospital stay. One recent study found a link between malnutrition and severe cases of COVID-19.2 Other studies have identified longer-term impacts, including a link between severe acute malnutrition in childhood and lower cognitive testing seven years after treatment.3

Food insecurity is also a medical issue—one with serious implications for people with diseases and medical conditions affected by diet.

A variety of groups—including federal and state governments, community-based organizations, healthcare payers and providers, and private food companies—would have to work together to improve the health of the most vulnerable communities by meeting those communities’ nutritional needs. As the primary source of benefits for many, healthcare payers have a significant opportunity to improve nutrition and have a positive impact on health.

Many payers understand this and offer these services today. Many states provide home-delivered meal services through waiver programs or Managed Long Term Services and Supports (MLTSS) programs, and 55 percent of Medicare Advantage plans in 2021 offer home-delivered meals or food and produce benefits4 for older adults through Medicare Advantage supplemental benefits. Early evidence suggests that medically tailored meal programs lead to fewer emergency-room visits5 and admissions to hospitals and skilled-nursing facilities6 for patients with specific nutritional needs, as well as lower monthly medical spending7 per patient. One 2020 study of medically tailored meal offerings for patients with type 2 diabetes8 found that program participants reported numerous positive side effects, from improved quality of life to reductions in stress. Another study found that programs designed to help patients meet basic nutritional needs can achieve a monthly net healthcare savings of up to $200 per patient.9

The recent adoption of nutrition benefits by many payers represents a significant step forward in helping individuals and society, and it may even help payers retain members and reduce costs. While these programs are already having a positive impact, there is an opportunity for some payers to realize even greater benefits by refining targeting and personalization, reinforcing partnerships and referral pathways, and taking a holistic approach to quantifying impact on health and business outcomes.

The role of healthcare payers in food security

Poor nutrition is a meaningful health risk factor that affects six in ten adults with a chronic disease.10 Across the United States, regions in which a larger percentage of the population does not get enough to eat on a regular basis tend to have higher rates of chronic illness such as diabetes, obesity, and hypertension (exhibit).

Across the United States, regions with higher food insecurity also have higher rates of chronic illness.

Moreover, many people enrolled in public health-insurance programs are food insecure. Among people on Medicare, 38 percent of those under 65 years old are food insecure, as are 9 percent of those over the age of 65, according to one study.11 Among adults on Medicaid, one study found that 23 percent overall reported food insufficiency in July 2020,12 with that figure jumping to 31 percent for those reporting fair or poor health (relative to 13 percent among those in excellent or very good health).

Medicare Advantage, many state Medicaid programs, and other payers have begun to explore three types of support to improve nutrition and combat food insecurity for vulnerable communities: home-delivered meals, medically tailored meals, and general food services. These offerings are not mutually exclusive, with many home-delivered meal programs tailored to specific medical needs.

Home-delivered meals. The majority of nutritional benefits offered by payers to date have been home-delivery programs, including services from partners such as Meals on Wheels and Mom’s Meals. For people who have chronic conditions, are recovering from surgery, or have injuries or other functional or mobility limitations, home deliveries relieve the burden of purchasing or preparing food.

Medically tailored meals. More recently, some payers have begun to offer meals that are medically tailored to specific circumstances. In a medically tailored meal benefit, food that is customized to a person’s medical condition and nutritional needs is delivered to their home several times a week for a specific purpose and duration, often for postoperative or postnatal care.

General food services. Finally, some payers offer members nontailored food services in the form of grocery-store discounts, gift cards, or referrals to food pantries. They also partner with community-based organizations to connect members to food support and classes on cooking or nutrition. While these benefits may be available to a wider group of patients and for a longer duration than medically tailored offerings, they have generally been limited to pilot programs and have not been widely scaled to date.

Barriers to scaling nutritional benefits

Despite growing evidence of the benefits of nutrition support for food-insecure members, many payers have encountered challenges in scaling these programs beyond a specific target population or an initial pilot. Common challenges include quantifying nutritional needs, designing targeted offerings, partnering with nutrition providers, and measuring health and business outcomes.

Quantifying need

While nutrition-support programs can have the greatest impact on food-insecure members, many programs are designed for the general-member population or those in specific medical circumstances (for example, postoperative or postnatal). In part, this stems from the challenge of precisely identifying members experiencing food insecurity. Healthcare providers and payers rarely collect consolidated data on members’ nutritional needs or food-security status.13 In some instances, payers only have access to these types of data once per year, which is not frequent enough to determine whether members need nutritional support due to seasonal work or if they are compelled to choose between paying for food or higher heating bills in winter.14

Designing offerings

Second, while payers and providers are careful to design offerings to accommodate a range of dietary requirements, cultural requirements, and menus, offerings are rarely tailored to address the structural conditions leading to food insecurity. For example, a program may offer two weeks of home-delivered meals for a member discharged from the hospital after being diagnosed with type 1 diabetes. While this could be sufficient for a food-secure patient, a patient experiencing food insecurity may be unable to maintain a nutritious diet once the benefit ends, leading to negative health consequences.

Partnering with nutrition providers

Third, the food-service landscape is highly fragmented, and partnerships are often limited by the geographic scope of providers. With the exception of some nationwide nonprofits such as Meals on Wheels and Feeding America, most community-based organizations that work with payers have only a local or regional presence and limited capacity to expand. This inability to scale has been a stumbling block for larger healthcare payers—especially those with millions or tens of millions of members—that need or want to provide services in a timely manner across multiple markets.

Similarly, referral pathways for nutrition programs remain a substantial challenge and can inhibit use of benefits. Members may lack awareness of food offerings—especially members with fewer resources, who stand to receive the greatest benefit from nutrition programs. Likewise, healthcare providers and primary-care physicians may be unaware of the potential benefit of nutrition support15 or lack the resources to support members in a time-intensive referral to federal assistance programs such as the Supplemental Nutrition Assistance Program (SNAP). Less than 1 percent of lecture time in typical US medical training is devoted to nutrition education.16 Likewise, one study found that while 94 percent of primary-care physicians agreed that it was their obligation to discuss nutrition with patients, only 14 percent felt qualified to do so.17 Finally, technology incompatibilities can inhibit referrals when nutrition partners use different data-reporting and collection systems from those used by payers and providers.

Measuring outcomes

Finally, the health and business outcomes of nutritional support programs are not well understood, in part due to the difficulty in directly tying nutritional support to health outcomes in short-term pilot studies.18 While food insecurity can have a wide-ranging impact on a person’s livelihood, schooling, or family, it can be difficult to measure specific metrics of a program’s success from a traditional health perspective. On the business side, nutrition benefits are rarely evaluated against traditional business goals, such as health-plan quality, cost of care, and member retention. While the limited scope and scale of programs to date has discouraged robust evaluation, measuring outcomes against business goals can help payers understand how to make these programs sustainable and profitable.

Actions that can improve the scope and impact of nutritional benefits

Healthcare payers can overcome these challenges and realize the full potential of nutritional benefits by taking a proactive, systematic approach to identifying food-insecure members; creating personalized nutrition programs designed to preserve dignity; fostering robust partner networks; and applying a broad lens to program measurement and assessment. Beyond these actions, payers can support additional research to further detail the link between nutrition and health and to determine their optimal role in improving food security.

Quantifying need

First, to target nutritional benefits for the greatest impact, payers can identify which individuals or groups within their member populations are experiencing food insecurity by collecting additional data, including payers’ own data and data from healthcare providers and public records. Payers can screen member groups or ask members directly about their food security.19 They can also ask healthcare providers to add codes related to food security to patient-billing systems and may consider offering financial inducements to do so. The Massachusetts Food is Medicine State Plan,20 published in 2019, recommends that payers create financial incentives for providers that build food-security screenings and referrals into patient care.

Overlaying these data with public indicators of food insecurity, including age, employment, education, and socioeconomic status, can help payers identify members who may be food insecure. A critical goal is to identify all the members or groups that need help, including those with near-term needs—such as those recovering from surgery or pre- or postnatal patients with special needs—and those with chronic conditions that require long-term food support, such as homebound patients with physical limitations.

Designing offerings

Member surveys can highlight who is food insecure and what support is needed, allowing payers to design targeted solutions to meet those needs. Targeting a food-security strategy to connect to the organization’s overall mission can help a payer decide whether it is more beneficial to design broad or deep solutions. If a payer’s priority for food support is focused on a specific population or condition—for example, to provide care programs for people with diabetes or another segment of the population—food-security initiatives can zero in on that goal. If a payer’s goals are broader, such as supporting members who fall below the federal poverty line, then a solution could include helping people enroll in SNAP or similar programs. In one instance of this, California’s state-run health plan launched a pilot program in 2018 that provided three medically tailored meals a day for 12 weeks to beneficiaries with congestive heart failure.21

Providing nutritional benefits to people in need does not always require delivering food to someone’s home or providing direct meal vouchers. It could entail funding or holding cooking classes so that someone with a chronic or acute condition can prepare the food a healthcare provider has recommended. Benefits could also include helping people understand which foods to choose or avoid at a food pantry based on their medical condition or health needs. Benefits may extend to an array of digital options, including apps for calorie tracking, food journals, and nutritional information as a supplement to other nutritional benefits.

Nutritional benefits are only likely to succeed if they meet people’s food needs and are user friendly. To increase the portion of eligible members who take advantage of benefits, payers can make it easy to sign up for programs by updating online enrollment portals, enhancing mobile apps, and providing sign-ups and customer service in multiple languages spoken in the community. Other ways to make programs more patient friendly could include simplifying eligibility screenings and encouraging members to provide feedback about their experience.

All benefits should be provided in a way that recognizes and respects members’ dignity. To avoid insensitivities, payers and providers can coach discharge coordinators on the appropriate language to use when asking patients how they expect to meet their food needs after being discharged. When evaluating outside contractors, payers can ensure those third parties adhere to the same principles of providing food support with dignity and respect.

Partnering with nutrition providers

Once a payer has developed a set of solutions, it can create a delivery ecosystem to provide the right services at the right time. This involves determining whether existing partners can deliver new or reconfigured nutrition programs under existing contracts or if payers need to revise contracts or find additional partners. Taking a comprehensive approach throughout this process will help payers leverage all available resources, including private food-service vendors as well as nonprofits and community-based organizations, which are well positioned to meet the needs of food-insecure members within their own communities. When California launched its pilot medically tailored meal program, the state contracted the Bay Area nonprofit Project Open Hand to manage it.

In addition to a robust partner network, payers may have the opportunity to improve program adoption and usage by promoting referrals from general practitioners and ensuring that their technology systems are integrated with those of food vendors. To healthcare providers in particular, payers can offer education and training about nutrition programs and work with care coordinators to promote usage of food services for those who would most benefit from them, including resources to support referrals to SNAP and other federal assistance programs. Previous research suggests that many primary-care physicians would be receptive to more nutrition education and resources to support referrals.22

Measuring outcomes

Finally, payers can take a broad view when determining how to measure the impact of nutrition initiatives. For example, they can expand the list of metrics they use as indicators of success, including markers of a program’s impact on near-term care. These could be reduced hospital visits, how frequently people use a benefit and how satisfied they are with it, and if it helped them stick to a medication regimen. They can also include markers that indicate impact on long-term health, such as an individual’s own assessment of their healthy days, mental health, and stress levels.

If a wide-scale rollout of expanded nutrition benefits is out of reach due to resource, budget, or other reasons, it is OK to start small. Payers can use pilot projects to test solutions, see what works, and make adjustments and expand. Testing and iteration in program design provide an opportunity to rethink the metrics that are used to measure successful outcomes—not just of pilots but of programs in general—to ensure that the outcomes are meaningful to the groups receiving the benefit. For instance, payers can measure nonclinical outcomes—such as whether a food-based benefit reduces the frequency of self-assessed food insecurity, leads to better economic stability for individuals and their families, or causes them to miss fewer days of work.

The recent growth of nutritional support programs among US healthcare payers represents a significant step in the right direction for improving members’ health and well-being. While more research is needed to establish the relationship between nutrition and health—research that every group in the healthcare sector has a vested interest in supporting—payers have a significant opportunity to build on the success of these programs, scale to wider populations, and address the rising societal challenge of food insecurity.

Beyond improving health outcomes for a vulnerable population, expanding nutrition benefits is also great business—with the potential not only to increase members’ health and happiness but also to lower overall care costs and provide a point of differentiation in a highly competitive market.

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