1. Food is Medicine is evidence-based prevention and empowers people to meet their health goals

Unhealthy diets are linked to higher costs and poorer health outcomes. By one estimate, food insecurity among people with diabetes is almost twice as high. In children, food insecurity is linked to worse health outcomes. Barriers to healthy eating include:

• The rising cost of food: Survey after survey shows that while Americans want to eat healthier, they often can’t prioritize it due to the higher cost of healthy foods. 
• Inadequate internet access not only limits telehealth services, including effective telehealth nutrition counseling, but also makes it less efficient to apply for federal nutrition benefits like SNAP. 
• Access to nutritious food: Food insecurity, while associated with “hunger” and absence of food, just as commonly predicts risk for chronic diet-related illnesses. Families often lack access to nutritious foods and are forced to rely on low-nutrition calorie-dense foods because they’re more affordable and accessible for low-income families with limited time, particularly when working multiple jobs. 

 

To empower people to make healthy food choices, Food is Medicine leverages the healthcare team to use its position of trust and skill in promoting behavioral change to support patients in changing their diets to prevent and treat chronic illnesses. FIM recognizes that nutrition education and access to nutritious foods are equally important, and that for some, eating healthy isn’t a matter of knowledge or skills, but one of affordability and access. By temporarily increasing nutritious food access, FIM enables patients to learn by doing – applying techniques from nutrition education.

FIM protects the federal taxpayer by reducing avoidable utilization

Food insecurity is linked to $2,500 higher household healthcare expenditures per year due to increased avoidable healthcare utilization and costs. With FIM, families can purchase more nutritious foods and eat balanced meals, thereby better managing or preventing diet-related chronic illnesses. FIM improves outcomes and reduces avoidable care costs:

• WIC is linked to reduced risk of preterm birth and infant mortality, but there are wide participation gaps, with 61% of Medicaid participants not enrolling in WIC despite being automatically eligible (among women, infants, and children). CMMI models that prioritize WIC navigation assistance for pregnant and postpartum mothers could lead to NICU savings and further savings across the child’s life course by preventing preterm birth and its complications for mother and baby. 
• For SNAP, multiple studies have found that enrolling in SNAP is linked to healthcare savings. Those estimates range from $1,400 per adult Medicaid participant ($4,100 for those with heart disease) to $2,360 per dual-eligible adults. 
• Produce prescription programs lead participants to have higher-than-average fruit and vegetable consumption. Medically tailored meals (MTM) are linked to fewer hospitalizations and nursing home admissions and are effective for tertiary prevention, such as low-sodium MTM for people with congestive heart failure. 
• The NC Healthy Opportunities Pilot found $85 in savings per member per month ($1,020 annually) for Medicaid enrollees participating in healthy food programs. In Massachusetts, the Medicaid-funded Flexible Services Program’s nutrition supports was associated with fewer hospitalizations and emergency department visits.

MFSN works with state partners to develop In Lieu of Services and Medicaid administrative changes to support FIM, inclusive of SNAP/WIC navigation assistance and nutrition counseling. We welcome partnership with CMMI to address food affordability within the innovation model nutrition supports.

2. CMMI should include a Health-Related Needs Screen and Intervene component in all models

A ”Screen and Intervene” framework should be embedded throughout Medicaid systems. Food and nutrition security screening is low-cost and minimally invasive, allowing identification of people at risk of diet-related illnesses before their health conditions worsen and become more costly to manage. Screening can enable connection to FIM at every level of prevention, with the choice of intervention depending on the healthcare team’s screening and nutritional assessment. Below, we present a starting point for mapping FIM against the three levels of preventive care (inspired by the Tufts FIM Pyramid):

Prevention level	Best practice interventions
Primary prevention (prevention before disease emerges)	Produce prescriptions or medically supportive food boxes Navigation assistance to access SNAP and WIC Nutrition education
Secondary prevention (prevention after disease or injury, like a heart attack)	Medically tailored groceries and/or temporary home-delivered meals to stabilize acute medical situations Navigation assistance to access SNAP and WIC Nutrition education
Tertiary prevention (preventing an ongoing disease from getting worse)	Medically tailored meals geared towards treating chronic diseases like diabetes, heart failure, or kidney disease Navigation assistance to access SNAP and WIC Nutrition education

3. CMMI should develop, scale, and measure whole-family care models

CMMI should develop value-based payment (VBP) models that incentivize healthcare systems to shift the whole family’s behaviors. Getting a child to eat better and prevent chronic illness requires access to healthy food and behavior change for the whole family. Childhood obesity prevention is more successful when they focus on both parents and children. And young kids may need to try a food 10 to 15 times before accepting it. That means families need additional resources to afford nutritious food to feed their children. Taking a whole-family approach to model design will both control current and future Medicaid costs. 

 

Community organizations are already a major provider of whole-person care services like FIM, but need additional support to operate in the Medicaid system. CMMI highlighted examples like the Medicare Diabetes Prevention Program and ACO REACH, in which a clinic organization made home visits, waived copays, and provided transportation funds to reduce barriers to attending appointments. CMMI should continue establishing incentives and flexibility for healthcare entities and community partners to deliver whole-family care to reduce barriers to healthy eating.

 

These models could inform CMS development of nutrition metrics for Medicaid and CHIP, as called for in the draft MAHA Commission report. CMS could consider including in its Medicaid Core Measures metrics like food and nutrition insecurity rates (paired with biometrics like HbA1c); rates of connection to SNAP, WIC, and other FIM programs for patients with food insecurity and diet-related illnesses; and household-level diet quality. There are also continued opportunities to measure the impacts of FIM on Medicaid enrollees, and CMMI could also consider how to orient impact measurement at the household level to capture the full effects of nutrition supports for families and children. 

 

As CMMI puts its MAHA Framework into practice, MFSN is excited to bring along our network of food and nutrition security/FIM organizations, healthcare partners, and Medicaid enrollees to participate in CMMI innovation mode co-design. MFSN is also excited to partner with CMMI to share best practices and case studies on VBP programs that include FIM.