You are what you eat. There is no denying the importance of good nutrition. A healthy diet can lower the risk of some conditions, and an unhealthy diet can increase the risk or exacerbate chronic conditions. Obesity, hypertension, high cholesterol, type 2 diabetes, heart disease, stroke, and some types of cancer are clearly linked to food choices. A growing chorus of experts say what’s good for the heart is good for the brain —some diets can decrease the risk of heart disease, and healthier food choices may help to prevent or delay Alzheimer’s disease. In no small way, food is medicine.
So, what are payers doing to influence what you eat? Likely more than you think and less than they should. And payers’ efforts have taken a bite out of different parts of the problem.
Healthy choices
People often make poor choices when eating. They reach for soda rather than water, cookies and cakes rather than fruits and vegetables, and candy rather than nuts. They often eat too much and too fast. Some of this behavior is due to a knowledge gap, and some payers are trying to fill that void.
United’s Real Appeal program offers eligible members an online weight-loss program that includes personalized coaching, nutrition education, tools for tracking diet and exercise, and a food scale. And it seems to work. One study demonstrated weight loss — active participants lost an average of 3.5% body weight, and those who completed the program lost an average of 4.3% of their body weight. Another study showed that participants had significantly lower medical costs relative to nonparticipants, and that cost savings increased with engagement. Medical costs were, on average, 6% lower for those attending four or more coaching sessions, and 16% lower for those attending 26 or more coaching sessions. Still another study demonstrated an ROI of 2:1 over a 3-year period, though this study did not account for pharmacy costs.
Google is one of several employers that provide healthy snacks, beverages, and meals to employees as part of its wellness initiatives. Google’s approach is designed to make the healthiest choice the easiest choice. But it is not only about what Google serves employees; cooking and gardening classes are also offered. Google does this because it is smart — and it has the advantage of being rich, which eliminates the cost barrier. Of course, it may also be doing this to boost productivity, decrease absenteeism, and help attract and retain talent.
The Affordable Care Act required most health plans to cover diet counseling for people at higher risk of chronic disease, as well as no-cost obesity screening and counseling. Some plans may now cover counseling because they have to, while others may do so because they want to. It is not clear whether the quality of these services and outcomes varies between plans.
Achieving member engagement and adherence is challenging. Additional research is needed to help payers optimize the incentives or rewards for programs designed to modify behaviors related to healthy eating, including shopping and cooking.
Eating right when not feeling well
When people are sick, including those recently discharged from a hospital or nursing home, eating right is critically important for helping the recovery process and to avoid worsening and readmission. But eating right can be challenging for someone who is recently discharged or who has or a chronic condition and finds healthy shopping or cooking too taxing.
Humana’s Well Dine program delivers fully prepared, nutritious meals to eligible Medicare Advantage members’ homes at no cost after an inpatient stay at a hospital or nursing facility. Humana’s program has reduced hospital readmissions. United’s Healthy at Home program similarly provides benefits, including 28 home-delivered meals, to Medicare Advantage members for up to 30 days after inpatient and skilled nursing facility discharges. Hopefully, this type of takeout takes off.
Eating just what the doctor ordered
Several Medicaid programs embrace the “food is medicine” concept by providing medically tailored meals (MTM) to beneficiaries with specific chronic conditions or nutritional needs. California, Pennsylvania, Massachusetts, Ohio, Rhode Island, Vermont, and New York have MTM programs. In one study, MTM receipt was associated with significantly fewer inpatient and skilled nursing facility admissions. Another study showed how participation in an MTM program for at least six months reduced ED visits, admissions, and medical costs. While the authors did not conduct a cost-effectiveness analysis, the lower estimated spending suggests that MTM programs may yield savings to payers, or at least be cost-neutral.
Payers could boost their ROI by targeting conditions where MTM has been shown to help manage the disease and prevent or slow progression. And payers should explore where MTM may yield additional savings (e.g., members undergoing chemotherapy and other debilitating acute treatments).
Eating well on a limited budget
Tragically, some people don’t eat well because they simply can’t afford to. They may or may not need education and counseling, and an illness may not be slowing them down. They need food that costs less.
Some payers help to put healthy food on members’ tables by helping them enroll in the Supplemental Nutrition Assistance Program (SNAP). For example, Cigna’s Foodsmart program — which gives eligible members up to three no-cost visits with a registered dietician who provides personalized nutrition support and counseling — also helps members to register for SNAP. While SNAP enrollment assistance was a response to COVID-19–related food insecurity, its endurance is a silver lining of the pandemic.
Payers could and should do much more for members facing food insecurity. Not just because it is the ethically and morally right thing to do. They should do it for economic reasons — it can lower their costs.
A menu of options
A comprehensive approach is a winning approach. To effectively manage a range of diet-driven diseases, Kaiser Permanente’s Food is Medicine Center of Excellence relies on evidence-based food and nutrition interventions, such as medically tailored meals, produce prescriptions (called Produce Rx) to help patients with diabetes have access to fresh produce, culinary medicine, nutrition counseling, and programs that help people afford healthy food. Kaiser has also helped more than 123,000 members apply for SNAP.
More to chew on
Some enlightened payers are earnestly addressing social determinants of health including food insecurity. These payers embrace the “food is medicine” philosophy and are trying to ensure that their members have access to the nutritious foods. It would be interesting and instructive to unpack the fruits of their labor.
And there are signs that payers are giving meal benefits greater weight. For example, in 2023, 78% of Medicare Advantage enrollees were in individual plans with meals as an extra benefit (86% in special needs plans), up from 71% in 2022. UnitedHealthcare offered meal benefits in 83% percent of its Medicare Advantage plans in 2023, compared with just over half in 2022. Whether an uptick in meal benefits reflects a philosophical shift or is simply a means to attract and retain enrollees, members benefit.
There are many explanations for why many payers don’t make additional investments in healthier eating. Helping members eat better incurs upfront costs, and some savings are likely realized over the long term. Social determinants of health, like food insecurity, present operational, measurement, and technological challenges. Some payers may conflate good nutrition with obesity, the significant challenges associated with behavior modification, and people’s struggles to lose weight and maintain weight loss through diet alone or in conjunction with exercise and/or drugs.
And when payers are distracted by other priorities driving spend and trend — like GLP-1s —resources that would otherwise be dedicated to social determinants are diverted to immediate needs. It is ironic that the use of GLP-1s for weight loss may limit the resources payers give to diet and nutrition.
Payers are typically much more comfortable reimbursing drugs, procedures, and tests than fruits, vegetables, and whole grains, and typically more focused on treatment than prevention. But eating well is so much more than losing weight. It is about preventing disease and promoting health and healing. It’s about reducing hospital admissions, readmissions, and ED visits. Payers will surely eat the costs of not helping members eat better. When they do not optimize investments in members’ nutrition, payers are penny wise and pound foolish.
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