Food Is Medicine: A Primer on Health System Initiatives in Texas

Overview

The Texas Consortium for the Non-Medical Drivers of Health is a statewide organization that advances the integration of non-medical services into the health care delivery system to improve health outcomes and reduce health disparities. The Consortium brings together those engaged in research, policy, and practice to learn together and build a field of practice across the state of Texas.

While the Consortium  is interested in all non-medical drivers of health, in our first year of operating, we are focusing on food and nutrition because of the proliferation of food-related programs sponsored by health care organizations across the state and the interest expressed by stakeholders, including government, in expanding this work.

The importance of food and nutrition in the prevention and management of health conditions is well-documented. Across the U.S. and Texas, programs incorporating food and nutrition into health care delivery are among the most common non-medical interventions implemented by providers and payers. These interventions have been described as "Food is Medicine" (FIM) programs. 

The purpose of this issue brief is to identify and describe the types of FIM programs employed by health care organizations to incorporate healthy food into service delivery to impact patients’ health outcomes. This will enable the Consortium and our stakeholders to use clear and consistent terminology in our FIM work. The clarity will support expansion of FIM programs across the state, which the Consortium aims to facilitate.

To develop the Consortium’s terminology, we reviewed the literature regarding the incorporation of food into health care delivery and the programs offered by health care organizations in Texas and elsewhere. Based on that review, we identified three distinct types of programs, named and described in this paper, which the Consortium will use in our work. The three program types are: medically tailored meals (MTM), medically tailored groceries (MTG), and food prescriptions (Food Rx). 

A note about the scope of the Consortium’s FIM focus: We know that health care organizations offer many other programs relating to food including education, counseling, food pantries, and cooking classes, often in conjunction with FIM programs. We are also aware of and applaud the many non-health care organizations using food to improve health as well as those addressing widespread food insecurity. The Consortium’s focus on FIM is limited to programs in which health care organizations take an active role in getting particular foods to specific patient populations to improve their health and medical outcomes.

Introduction

Food is a need, not a want, and people must eat healthily to live well and live long. The goal of attaining optimal health and well-being appears out of reach for over 44 million Americans and 4 million Texans who are struggling with food insecurity. Food insecurity and diet are intricately linked such that those who are food insecure often resort to consuming energy-dense, nutrient-deficient foods that satisfy short-term hunger but undermine good health. Over time, this results in increased risk of diet-related chronic conditions such as obesity, diabetes, hypertension, cardiovascular disease, and various types of cancers. It is estimated that 85% of the $4.3 trillion in annual national health expenditures in the U.S. are spent on medical care for diet-related conditions, and an estimated 500,000 deaths in the U.S. are caused by diet-related chronic diseases.

Food is Medicine is an umbrella term for a number of interventions and services provided by health care organizations (health plans, health systems, clinics, and other providers) that address the critical link between access to healthy food and optimal health. The increasing interest in these programs is driven by a growing evidence base that shows the impact of these programs in improving health outcomes and in some cases, reducing health care costs. Payors of health care services, led by Medicare and Medicaid, are requiring and incentivizing providers to incorporate FIM into their service delivery.

There are an increasing number of opportunities for Texas health care organizations to develop and receive funding for FIM programs. For example, there are more than a dozen Medicare Advantage plans in Texas, and many include FIM offerings. The Texas Health and Human Services Commission also published its Non-Medical Drivers of Health Action Plan in early 2023, and named food as its top priority. And HB 1575 (88R), signed into law in June 2023, allows Medicaid to pay for screening and service coordination for pregnant women in need of nutrition support. Many Texas health philanthropies have provided grants to catalyze this work.

Texas Consortium’s Terminology for FIM Programs

In each of the programs described below, health care organizations provide FIM to patients who have screened positive for food or nutrition insecurity and have a diet-related medical condition for which improved nutrition can help. Screening tools and criteria for participation vary widely by program and sponsoring organization. Health care organizations usually implement their programs by partnering with food service organizations to deliver the food. As the field grows and more evidence is developed, we will likely see a coalescence around particular screening tools and criteria for patient inclusion in each program.

At this time, the Consortium is focused on defining the programs, accelerating adoption, and supporting research and evaluation of programs. Below we describe three distinct FIM programs and provide examples of each as sponsored by a Texas health care organization.

Medically Tailored Meals

Description

Medically tailored meal (MTM) programs distribute prepared meals to meet patients’ specific medical and nutritional needs. MTM programs are particularly important for people who do not have the ability to shop for or prepare meals. Typically, the meals are tailored to meet the macro- and micro-nutrient needs of the patient’s specific medical condition. Patients receiving the meals are often provided medical nutrition therapy, nutrition education, and nutrition counseling. In most programs, nutrition professionals assess patients, oversee the preparation and delivery of meals, and provide other nutrition-related services such as nutrition counseling or other educational opportunities. Meals are either delivered to patients’ homes or available for pick up. MTM is most often implemented through a partnership with a community-based organization with food and nutrition expertise. In addition to being nutritionally complete, the meals must be enjoyable to the recipient, which requires attention to the cultural preferences of recipients. The duration of MTM programs varies by patient condition and the amount of time to attain the intended outcomes, but typically patients are reassessed for need and eligibility periodically.

Example

Meals for Me: Managing Diabetes at Home is a program offered through Factor Health at The University of Texas’ Dell Medical School. The program aims to improve the mental health and hemoglobin A1C levels (i.e., a measure of long-term blood glucose control) of low-income, older adults with unmanaged diabetes by delivery of meals and accompanying social check-ins by Meals on Wheels volunteers. The program is designed as a three-arm, parallel randomized trial study to ensure that the impact of the MTMs is appropriately measured.

Medically Tailored Groceries

Description

Medically tailored groceries (MTG) programs involve an assessment and individualized planning process under a nutrition professional’s supervision, similar to MTM. Instead of meals, MTG provides minimally prepared groceries that meet the patient’s nutritional and medical needs and require preparation by the patient. Typically, the groceries constitute at least one meal a day and are delivered or available for pick up on a regular basis. Participants in MTG programs must be able to prepare healthy meals with groceries, unlike MTM recipients. These programs may include nutrition education and cooking classes to support recipients in using the groceries, and like MTM, attention to cultural preferences is critical. MTG programs generally last for several months and are often used as part of long-term disease management.

Example

UT Physicians offers an MTG program known as Brighter Bites Produce Rx through its pediatric clinics. The program aims to improve diet quality, food security, and physical and mental health outcomes among families with children ages 5–12 years who are overweight or obese and on Medicaid. As part of the program, participating families receive a card (similar to a debit card) that is loaded with money on a monthly basis and can be used to purchase fresh produce at participating grocery retail stores. Families also receive robust nutrition education through the Brighter Bites nonprofit. The program is designed as a three-arm, comparative effectiveness randomized controlled trial to assess the impact of this approach as well as that of home delivered produce boxes on prevention of diet-related chronic conditions starting early in life.

Food Prescriptions

Description

In these programs, health care providers offer patients prescriptions, usually in the form of vouchers or debit cards, that allow them to procure prescribed food items, usually for a prescribed period of time. Most often the prescribed foods are fruits and vegetables, although some food prescription programs include whole grains, lean protein, and low-fat dairy.

There is a significant variation in the procurement mechanisms of this food. In some programs, the provider has food onsite for prescription fulfillment; in other cases, patients use their prescriptions at food banks/food pantries. Other programs may allow patients to opt for home delivery of a produce box at consistent time intervals, while still others may allow patients to use their prescriptions at participating grocery stores. In some programs, patients choose their food from the prescribed selection, while other programs offer pre-prepared food boxes for pick up. Food prescriptions may also include services to further encourage healthy eating behaviors, such as nutrition education and culinary classes. They typically last for six months and may be extended if appropriate, depending on patient outcomes.

Example

Harris Health System’s Food Farmacy provides prescriptions for its patients with uncontrolled diabetes to receive 30 pounds of fresh fruits and vegetables and other nutritious food every two weeks for an initial six-month period. The food is available at three clinic locations. Over 6,000 patients have participated in the program, and an evaluation of the program revealed a clinically meaningful drop of one percentage point in hemoglobin A1C levels for enrolled patients as compared to non-enrolled patients. The program offers nutritional guidance from nurse educators, registered dietitians, and community health workers, in addition to assistance in qualifying for external social service programs.

Next Steps for the FIM Movement in Texas

Increasing Investment in FIM Programs

Health care organizations must take advantage of the emerging state and federal requirements relating to screening of and referral for food-insecure patients to develop FIM programs. For example, CMS is increasing its expectations of health care providers participating in Medicare and Medicaid to screen for and address the non-medical needs of their patients. Likewise, HEDIS is incorporating standards relating to non-medical needs into their quality measurements, which are used by government, businesses, and individuals to rate health insurance plans. And the Texas Health and Human Services Commission now has a Non-Medical Drivers of Health Action Plan. In addition, the Texas Legislature just passed a bill requiring screening and referral for pregnant women in Medicaid in need of food and other non-medical services. We urge plans and providers to accelerate their investment in FIM as these requirements advance.

Expanding the Evidence Base in Support of FIM Programs

Texas health care organizations have responded to the food security need in our region with a plethora of food-related programs. However, the programs vary in dosage, reach, and implementation, and many lack sufficient evaluation. The effectiveness and cost-effectiveness of these programs using stringent research designs, including a comparison group remains sparse. This research is essential to determine best practices and advocate for increased investment. Partnership with research and academic institutions will allow for building the evidence base to inform FIM programs and accelerate the movement to add food as a covered health benefit.

Building Financial Sustainability for FIM Programs

We must use all available levers to incorporate sustainable funding from the health system to underwrite successful FIM programs. Many of the current programs were funded by philanthropy and initiated by nonprofit organizations to achieve health equity. Philanthropy is an important funding source but cannot and should not have to pay for these efforts when there is $4.3 trillion invested in our national health system. There are current opportunities for funding FIM programs in Medicare and Medicaid, and Texas should take advantage of these. There are additional opportunities through Medicaid waivers that are being used successfully in other states to fund FIM programs.

How Should Not-For-Profits and For-Profit Organizations Participate in the FIM Movement?

FIM programs anchored in health care organizations have traditionally relied on community-based, nonprofit, food-related organizations as partners in providing food to patients. However, as the movement grows, for-profit organizations have entered the FIM space, especially as more opportunities to earn revenue from FIM programs, particularly MTM programs, emerge. In the future, we will need to understand how best to take advantage of both kinds of organizations to meet the health-related food needs of Texans.

Call to Action: Join the Texas Consortium for the Non-Medical Drivers of Health

The Texas Consortium is the only statewide organization devoted entirely to accelerating the integration of non-medical services into the health care delivery system. The Consortium has brought together hundreds of researchers, practitioners, and policymakers across the state to learn together about this burgeoning field. Our website holds recordings of the many related webinars hosted during 2023 as well as a searchable Program Index that catalogs health care organizations’ non-medical drivers of health programs in Texas. If you are interested in FIM and other non-medical programs, the Consortium is the place for you. For more information, please visit our website or contact Jacquie Klotz, program manager, at [email protected].

Selected Resources on FIM Programs

Food is Medicine Coalition

Food as Medicine Collaborative

Center for Food as Medicine

Food is Medicine Massachusetts

National Produce Prescription Collaborative

Harvard University’s Center for Health Law and Policy Innovation’s Food is Medicine

Gretchen Swanson Center on for Nutrition

Gus Schumacher Nutrition Incentive Program

Downer, Sarah, Emma Clippinger, Corby Kummer, and Kurt Hager. 2022. Food is Medicine Research Action Plan. Aspen Institute, January 27, 2022. https://www.aspeninstitute.org/wp-content/uploads/2022/01/Food-is-Medicine-Action-Plan-Final_012722.pdf.   

Platkin, C., A. Cather, L. Butz, I. Garcia, M. Gallanter, and MM. Leung. 2022. Food as Medicine: Overview and Report: How Food and Diet Impact the Treatment of Disease and Disease Management. Center for Food as Medicine and Hunter College NYC Food Policy Center, March 30, 2022. https://foodmedcenter.org/wp-content/uploads/foodasmedicine.pdf.   

U.S. Department of Health and Human Services. 2023. “Food as Medicine: A Project to Unify and Advance Collective Action.” Office of Disease Prevention and Health Promotion. https://health.gov/our-work/nutrition-physical-activity/food-medicine.

Volpp, Kevin G., Seth A. Berkowitz, Shreela V. Sharma, Cheryl A.M. Anderson, LaPrincess C. Brewer, Mitchell S.V. Elkind, Christopher D. Gardner, Julie E. Gervis, Robert A. Harrington, Mario Herrero, Alice H. Lichtenstein, Mark McClellan, Jen Muse, Christina A. Roberto, and Justin P.V. Zachariah. 2023. “Food Is Medicine: A Presidential Advisory From the American Heart Association.” Circulation 148, no. 18 (September 28, 2023): 1417–39. https://doi.org/10.1161/CIR.0000000000001182.

Weinstein, Olivia, Christina Badaracco, and Sharon Akabas. 2023. “Why Current 'Food Is Medicine' Solutions Are Falling Short.” Health Affairs Forefront, May 12, 2023. https://www.healthaffairs.org/content/forefront/five-food-problems-why-current-food-medicine-solutions-falling-short.

 

This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s), and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.