Colorado’s Medicaid agency, health care providers and nonprofits want more people to get nutritious food as part of their overall health care, but no one is sure how to fund something beyond the current patchwork of programs.
The “food is medicine” movement has gained traction in recent years as insurance providers and government agencies determined they could achieve better health outcomes, for less money, by improving people’s diets than by giving them medical treatment after their conditions worsened.
The Colorado Department of Health Care Policy and Financing, which oversees the state’s Medicaid program, has made nutrition a priority and plans to ask for federal funding to bring healthy food to more members.
As it stands, the state’s Medicaid program can only pay for meals for people with certain disabilities who recently got out of the hospital, left a nursing home, or are at risk of being placed in a facility because they lost their caregiver or had a major physical setback, such as an amputation.
Other health care providers and insurers have small-scale projects offering food to people with specific conditions, and nonprofits rely on donations to reach people who need food delivered but aren’t covered by one of the pilot programs.
If Colorado gets permission from the federal Centers for Medicare and Medicaid Services, the state could expand food support to broader groups, such as recipients who have chronic conditions or high-risk pregnancies, said Adela Flores-Brennan, Medicaid director at the Department of Health Care Policy and Financing.
The state could also offer less-intensive support, such as produce vouchers, she said.
“It doesn’t necessarily have to be (ready-to-eat) meals,” Flores-Brennan said.
Different groups have their own definitions of “food is medicine,” but in Colorado, most of the discussion has centered on produce prescriptions, food boxes for people with diet-related illnesses, or medically tailored meals.
A produce prescription could include either a debit card that can only be used for specific foods, or boxes of fruits and vegetables. Food boxes include most of the ingredients for healthy meals, possibly with instructions, while medically tailored meals arrive ready for the recipient to eat.
Critics of the approach argue that resources would be better spent on broader programs, such as improving the quality of school lunches and expanding the number of people who receive food assistance dollars.
The department still needs to consult communities and work out the details of its expansion plan, then submit it to the federal Medicaid authorities for approval. If it succeeds, the state would get federal matching funds, but that won’t happen for two years or more, executive director Kim Bimestefer said during a summit on nutrition policy in November.
Seven other states also have waivers allowing them to offer some nutritional support through Medicaid, though they vary in exactly what they offer and for which populations.
“We’re already getting pushback from elected officials on how can we truncate that timeline,” she said.
Since April, the state has offered meals for 30 days to some Medicaid members who just left the hospital, Bimestefer said. The department also is working on a tool to help connect members to services, including food assistance, she said.
“Even without that waiver yet, we can start,” she said.
Working to move the policy needle
Some of the organizations that administer Medicaid in different regions of the state have opted to use discretionary dollars they receive to improve health outcomes on meals for patients who have chronic conditions and difficulty purchasing what they need. Colorado Access is paying to get medically tailored meals to some patients with congestive heart failure and food boxes for some people with diabetes or heart problems in Denver.
Insurance companies and programs like Medicare and Medicaid are still gathering data to determine whether the food programs are producing the cost savings and clinical outcomes they hope to see, said Dr. Tamaan Osbourne-Roberts, chief medical officer at Colorado Access. If they do benefit patients, then the question will be how to fund it going forward, because the system isn’t set up to cover food the way it does medications or procedures, he said.
“We’ve built a health care system,” not a prevention system, Osbourne-Roberts said. “It’s taken a while to move the policy needle.”
The Colorado Access members who receive medically tailored meals get them through Project Angel Heart, a Denver-based nonprofit that produces about 13,000 meals per week. The group’s president and CEO, Owen Ryan, said all of the meals they make are suitable for people with diabetes or heart problems, and they can alter the recipes for clients who have food allergies, are vegetarian, need unseasoned food or have kidney disease.
The matching federal funds from a waiver would allow providers of medically tailored meal to scale up their operations, he said.
“We’re one of very few providers who can say we can make a heart-healthy, diabetic-friendly meal that’s gluten-free and doesn’t include pork,” Ryan said.
Project Angel Heart delivers meals in Colorado Springs, Pueblo and the Denver area from Castle Rock to Longmont. Over the next two years, it plans to expand to Loveland and Fort Collins. While some health care providers have contracts, foundations and individuals fund the vast majority of the meals, said Kristy Adams, director of marketing.
Most people don’t need a service as intensive as medically tailored meals, but for the sickest parts of the population, they can make a difference. A study using Colorado’s All-Payer Claims Database found that health care costs decreased by almost one-quarter when people with congestive heart failure, chronic obstructive pulmonary disease or diabetes received one medically tailored meal a day for six months.
“They’re little angels to me”
Food Bank of the Rockies has also gotten into the “food is medicine” space by working on a pilot program with a handful of medical providers to provide nutritious options for people who are less severely ill, President and CEO Erin Pulling said.
About 70 people with diabetes, pre-diabetes, cardiovascular disease or high blood pressure are receiving the boxes now. The program is nearing its end, but could continue if they can find the funding, she said.
One of the partners is Denver Health. Dr. Meg Tomcho, a pediatrician at Denver Health who helped start the partnership, said the clinics are still working on assessing the overall results of the food boxes, but she expects to see a benefit.
When doctors prescribe a pill, it may help with one disease, but healthy food makes it easier to manage multiple conditions, she said.
“We are really trying to take the barrier of access out of the equation,” Tomcho said.
By the food bank’s standards, medical food boxes are a high-cost program, because they have to purchase specific foods and hand-deliver them, Pulling said. The boxes cost about $26 each and contain about 11 meals, whereas the food bank can provide about three meals for $1 when using donated food and the typical distribution channels. When compared to the cost of a hospital stay, though, the program is a bargain, she said.
Valerie Maes, of Denver, said her doctor referred her to the food bank program because she was having difficulty controlling her blood sugar. She said the boxes helped her to come up with new go-to breakfast and lunch options that keep her diabetes under control.
A recent box included chicken, pinto beans, brown rice, oatmeal, canned fruit and vegetables, potatoes, carrots, mandarin oranges and a large green fruit that she didn’t recognize but thought was delicious.
The food bank staff not only dropped off the boxes, but checked in on her regularly and helped her to sign up for nutrition assistance, which she didn’t think she would qualify for, Maes said.
“I always tell my friends, ‘They’re little angels to me,’” she said. “It helped me to see that I could get better. I could feel better.”
“It’s like you flip a switch”
Much remains unknown about how best to use nutrition to improve health, including the correct “dose” of food for different populations.
Kaiser Permanente Colorado conducted a trial in comparing outcomes when patients leaving hospitals received two or four weeks’ worth of meals, and found no significant difference, said Dr. Wendolyn Gozansky, the health network’s chief quality officer.
If that’s correct, the best approach might be to give the meals to more people for a shorter time. But depending on the group of people, the optimal length may be shorter or longer, she said.
Kaiser Permanente Colorado asks every patient who comes in for an appointment if they want help with food, transportation or other necessities, and has a call center with staff trained to help connect people to resources, Gozansky said. The health care provider is still evaluating how that’s going, but anecdotally, doctors seem to like having someone to help meet nonclinical needs they don’t have time or expertise to cover, she said.
The federal government is also studying how food can improve health. Luis Perez, a dietitian and researcher with the U.S. Department of Veterans Affairs in Aurora, said he found that patients who were receiving dialysis and hadn’t succeeded in cutting the salt in their diets on their own were able to make significant reductions when they received three medically tailored meals a day for four weeks. The reduced salt led to decreases in blood pressure and fluid retention, he said.
Perez said he’s still studying how best to extend the effects after the meals stop. Hopefully, recipients will have a better idea of what they need to eat to manage their condition, though it might be a good idea to gradually reduce the number of meals while they adjust, he said.
“We provide these meals and it’s like you flip a switch. It’s like night and day,” he said.
Sign up for our weekly newsletter to get health news sent straight to your inbox.