Sustainable Funding

[NOTE: This page is now out of date for Vermont specific information and funding options - we are in the process of updating. This old page is left up during that process for background reference links. You can find a list of what we have recently updated for funding structures background at this Update post]

Standard disclaimer: this is educational background information only, it is not financial advice and does not represent any official policy positions of Bi-State Primary Care Association or our funders.  

Sustainable Funding Introduction

Integrating food access and health care requires startup funds to build new programs / approaches and sustainable funding to provide longevity. This overview focuses on the latter. However, the two can’t be fully separated. The startup phase funding is particularly relevant because often long-term health care funding streams require a high burden of proof for quality, clinical results, and cost efficiency (including specific coding and definition parameters to prevent fraud and abuse). 

If you want a glimpse into how medical services traditionally get approved for ongoing reimbursement, it’s well documented by Medicare - see for example the annual proposed changes to CMS’ Physician Fee schedule (linked here is CY22), details on the current Physician Fee Schedule, and commentary from MedPac (the Medicare Payment Advisory Commission). That example will also suggest why food as medicine projects often look for coverage under waivers, demonstration projects, and alternative payment models - it is challenging to get approved for reimbursement under conventional plans. 


While a goal of integrating food as part of health care might be to pay for food-based interventions “like any other medical service”, in reality there are hundreds of different ways existing services get paid for. The following reports identify specific opportunities to resolve the sustainable funding challenge for food in health care:   


While this site emphasizes strategies focused on food, food often appears in programs designed to address a range of social factors that influence health. This includes screening, referral, and navigation programs for accessing social services and community resources. For example: 

 

Along this theme, in September 2021, the Government Accountability Office called on Congress to better coordinate cross-sector funding of efforts to address diet-related causes of chronic disease.

“Congress should consider identifying and directing a federal entity to lead the development and implementation of a federal strategy to coordinate diet-related efforts that aim to reduce Americans' risk of chronic health conditions.”

To go one step broader, there is no rule that health funding needs to be the starting perspective. Some analysts take the neutral starting point of simply asking how to break down funding barriers between sectors. 

And to see the braiding and blending concepts applied to health policy:

The following sections offer examples and details on three types of health-related funding that all work together to promote integrating food and health care: foundational food access, population health & community programs, and funding tied to individual patients’ health outcomes. 


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Types of Funding for Food and Health: 

If we attempt to simplify the overlapping worlds of money, health care, and food access, it could start with three broad varieties of activity, each with their own spending priority. The idea of this using this structure as a starting point is also covered in a bit more detail in this 2021 presentation (the link is to an annotated PowerPoint):

  1. Foundational Food Access Programs -often connected to the USDA. They're focused on getting volumes of food out into the community. These don’t only address the quantity of food available, they often include extra incentive for “healthy” options (e.g. produce). Federally funded programs like SNAP usually have income eligibility criteria; community and philanthropy funded programs tend to focus on minimizing barriers & being open to everyone without collecting individual information. These initiatives are often considered the foundation of more clinically-linked programs because grant money has gone in to figure out the logistics of the food side of the equation, from which health care practices can build up the clinical side. An example of this is the USDA GUSNIP funds for produce prescription programs and SNAP supplements - these begin in the food & agricultural realm moving from broad food access (SNAP), to community health (adding in more fresh produce), and now there’s a national conversation about bringing produce prescriptions into health care coverage for individual treatment.

  2. Population Health & Community Focused Programs - These programs build from studies on dietary patterns that lead to better health generally, for example reducing sugar intake or moving to a more plant-centric diet. The focus is education and behavior change across a community. These programs may include individual consultations with clinicians or health professionals for more tailored prevention, but not always. Behavioral economics models often appear here as programs attempt to change the external context of food, diet, and nutrition to reinforce healthy patterns. These programs may prevent diet-related health issues before they start, and they may also help individual patients respond positively to diet-based treatments recommended by clinicians (the next category) by making those concepts more familiar / more feasible to implement.


  3. Programs Tied to Individual Patient Outcomes - Where it's no longer enough to know that kale is healthy in general, we need to know it's doing something for this particular patient. Components of making this individual connection include: screening for clinical risk factors and/or social risk factors using a validated tool, tracking progress from referral to a food-based program through participation (ie the "dose" of the intervention), tracking / adjustment to be sure the intervention is working - including any necessary medication management and a defined time period for seeing clinical results. Sometimes this work happens internally for a health care practice. Often the work includes referring to a community based organization. Payment for food “like medicine” often refers to this category because this resembles traditional insurance. However, this application of food within health care may only be successful if the other two activity areas are supported. Medically Tailored Meals are an example of a food-based intervention that focuses on this space for both impact and reimbursement.


Overlaid on these categories, a meta-category is funding for coordination between all the health-related organizations and professionals that might interact with a patient. The health care system has a variety of ways these funds become available. FQHCs receive federal 330 grants to help address “enabling services” - services that break down the barriers to good health for their patients. The Blueprint for Health funds Community Health Teams that help coordinate services for patients.  Accountable Care Organizations (ACOs) provide a collaborative framework for reducing barriers across the health care system - including legal, data analytics, and payment elements - and OneCare Vermont is our statewide ACO. This overview does not focus on the broad category of coordination services. However, it is relevant to note that the cost of that type of work shifts when the scope moves from referring patients to partners in the community to having non-health care partners gain access to individual patient information, data, and direct billing to health care payers - an idea which will be reiterated in the section on programs tied to individual patient outcomes.


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Foundational Food Access Programs 

At the base of all of this work are the federal government programs that provide for essential access to food. These programs include:

 

States, federal grants, health care funding and charitable funding will complement these core programs - providing matching dollars for SNAP benefits spent at farmers markets, adding funds for fresh produce, supporting school backpack programs to ensure children have food for the weekend, for example. Health care funding could complement, but not replace these foundational federal programs. 

 

One concern in health care is to avoid cost shifting. The classic example is if the public payer insurance plans under-compensate for a service, and the difference gets shifted onto commercial plans to make a hospital system whole. Similarly, we don’t want it to become the responsibility of health insurers to make up the difference if a nutrition program is underfunded. It would not make sense, for example, to duck the question of reforming the SNAP food budget calculations by saying insurers should pick up the difference because better food access leads to better health. 

 

Organizations with funding to improve food access across a community often serve as partners to health care providers, bringing the expertise in sourcing food and getting it to community members. The Farm to Plate Food and Health Cross Cutting Team has an inventory of local food and health programs that includes overviews of their funding sources. Program examples are posted in the Increasing Program Impact page. 

In September, 2021, the Bipartisan Policy Center released an extensive report with policy recommendations for building from the current food and nutrition support infrastructure and lessons learned during COVID-19 to better support nutrition security. This report is the first in a series of three. It provides a detailed mapping of current program investments and ways they might be improved. For a broader perspective, the Rockefeller Foundation’s July 2021 report on the True Cost of Food in the U.S. also traces the impacts of food system decisions on health, health care, and the associated costs.

 

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Population Health & Community Focused Programs 

 

Community health programs can begin with support from any number of sources, government programs (federal, state, and local), community non-profits, health care providers, academic centers, businesses interested in employee wellness, commercial insurance, ACOs, schools . . . many places. One way to consider all these diverse programs is to highlight ways that they reinforce other sustainable funding pathways for food in medicine. Much like food access programs build a foundation for connecting people with the food they need, community focused programs also build pieces of the infrastructure for integrating food and health care. For example:

 

Translating Research & Data into Public Campaigns: Population health initiatives use data to design strategies and set priorities, and smaller scale projects can build from these frameworks to increase their own impact. From a ‘sustainable funding’ perspective that means reducing duplicative efforts in data analysis while also helping target investments to priority areas. See, for example, the 3-4-50 initiative from the Vermont Department of Health. This program engages multiple partners in addressing chronic disease and provides a scorecard for Vermont’s progress towards changing 3 behaviors that contribute to the 4 diseases that lead to over 50-percent of deaths.


Information Sharing and Outreach Systems: See our Outreach Systems page for specific examples of this type of investment. Outreach around diet and options for a healthy diet can range from extremely broad campaigns (think of 5 a Day - a global push to raise awareness of 5 servings of fruits & vegetables) to highly targeted efforts that borrow from market segmentation and other data-driven strategies (see this overview of Predictive Analytics). Community programs also use well-tested tools for sharing information / engaging individuals in a way that leads to individual behavior change, for example EFNEP (Expanded Food and Nutrition Education Program), which draws the networked researching capacity of land grant universities to support best practices in nutrition education.  

 

Changing the Food Environment: Changing the food environment can be a micro-scale, like making produce more appealing and healthy options the default choice, or more macro-level. Some regions combine the food access mapping of programs like Map the Gap or Food Access Research Atlas and data on community health outcomes to identify locations where better access to healthier food can have a significant health impact. See also this local map created for the Washington County Hunger Council and this UDS training on overlaying food access & health care data (7/22/21).

Shifting Health Care Investment “Upstream”: The economic premise behind “upstream” health care investments is that the least expensive way to treat disease is to prevent it, and many of the most costly conditions (for example type 2 diabetes) can be prevented through measures like changing diet. As one example of these investments, the Affordable Care Act requires non-profit hospitals to address community health needs, and Health Care Without Harm provides this ‘playbook’ describing how that connects with food programs. Payment structures like value-based payments managed through an ACO both increase the financial incentive to invest in prevention and establish legal structures to invest across the health care system (for example a hospital giving money to a primary care provider outside the hospital network, which would normally be prohibited). See, for example, RiseVT a program of OneCare Vermont.

 

These programs can be parsed in many ways and they feed directly into the next category of individualized health care plans. Consider, for example, a current debate over platforms for making referrals between health care organizations and community organizations and whether we might be better served if we treated them as a public good - it’s a community health investment that supports individuals’ plans of care and treatment. 

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Programs Tied to Individual Patient Outcomes:

The last piece in our puzzle is paying for food programs as a treatment or targeted prevention option for individual patients. If you want background on the different types of payers and the structure of health care payment in Vermont, there are a few options. Every year the Joint Fiscal Office provides policy overviews to the Legislature, including of health care issues. Here is the 2021 version of the Health Care System and Health Care Finance (COVID-19 was a separate briefing, this reflects 2019 data). If you want to get deeper into data, the Green Mountain Care Board provides publicly available analysis and data tools built from the claims database.

 

The following information gives examples of long-term reimbursement structures. As a reminder from the introduction, usually a significant amount of investment goes into building programs with proven health and cost benefits before they enter this “sustainable reimbursement” track for ongoing funding. Nationally there are many examples of this - for example in California where the state legislature funded a statewide demonstration pilot of Medically Tailored Meals or the Wholesome Wave foundation, which supported innovations in produce prescription programs that now inform USDA investments in this area. In Vermont we also draw on grants to support innovative projects, for example a State Innovation Model (SIM) Grant funded much of our preparatory work for payment reform (described later) and a CDC 1815 Grant supports new projects addressing diabetes and heart disease. OneCare Vermont has provided support for trying new projects through Innovation grants and the RiseVT Amplify mini-grants for community projects.  

 

Note that this is a two-step hurdle. First, establishing a clear model of a food program with clinical and cost evidence behind it (see our Data & Measurement section). Second, establishing the infrastructure at health care practices to implement such a model and connect it to individual patients’ treatment plans.  

 

This work has already occurred in many corners of the food in medicine world, and we can see examples of potential payment models. As noted earlier, this overview does not include the broader world of care coordination / care management, however here are examples of two well established systems of whole person care that highlight a food component:

Lifestyle Medicine - Lifestyle Medicine focuses on behaviors such as diet, exercise, and sleep as therapies and prevention. Many existing health care reimbursement options can include diet-focused services, for example, having conversations about diet in annual wellness visits or as part of mental health or in chronic care management. However, this integration requires clinician training and ongoing research, which is the focus of the American College of Lifestyle Medicine.

Patient Centered Medical Home - The PCMH model emphasizes access to comprehensive care in a primary care setting, including access to nutrition services and access to SDOH-related services. In Vermont, the Blueprint for Health supports practices in receiving PCMH designation.

These are two avenues supporting the services needed to create a care team context for food as part of health. They do not necessarily cover the food itself. Covering actual food requires flexible health care plans that reimburse non-traditional expenses. Below are some resources on this final component organized around three common food-based health interventions:

 

Medically Tailored Meals (MTMs) - Our Medically Tailored Meals page goes into what defines MTM, note that this is a very specific intervention not synonymous with healthy prepared meals. That page includes an overview of potential funding options relevant to Vermont. The Food is Medicine Coalition provides updates on national funding advocacy. MTM programs are distinct as a covered benefit because they link to specific diagnoses, and feature prepared meals in which a high percentage of daily diet is provided to the patient. Sometimes the OAA meal delivery programs, mentioned in the Food Access section, are used as a benchmark for the price of MTMs. That can be problematic because the cost and complexity of managing MTMs is significantly higher. The Vermont Agency of Human Services provided two reports to the Legislature in 2017 and 2020 on how our state might expand meal-based food services and increase their health impact, which overview reimbursement opportunities and challenges.   

 

Produce Prescriptions - In 2020-2021, the Center for Health Law and Policy Innovation (CHLPI) published an overview of funding options for produce prescriptions and an issue brief on produce as a Medicare Advantage benefit. North Carolina included this option in their Healthy Opportunities Pilot for Medicaid beneficiaries, and their work on setting appropriate fees and describing these prescriptions in a suite of food-related services may be informative for other states. This was done as a demonstration project under their 1115 Waiver. 

 

Medically Tailored Food Pantry - The Geisinger Fresh Food Farmacy is one example of a fully embedded food program in a vertically integrated health care network (in partnership with the Pennsylvania Food Bank). This project is focused on patients with Type 2 Diabetes and links together a care team with different specialties (including nutrition education and health coaching), cooking tools and education, and ingredients sufficient for 10 meals a week for each member of the household. Geisinger as a health system has been aggressive in promoting value-based payment models, including the Pennsylvania Rural Health Model that combines all payer types (Medicare, Medicaid, commercial) in a global budget system. The Fresh Food Farmacy includes core elements of ACO-style reform, including strong analytics and use of patient data, team based care approach, and an integration of health care delivery reform with payment reform / reducing cost of care.  

 

These different examples include some common components to consider when investigating sustainable reimbursement streams:

 

Phases of Value-Based Payment Reform: At the most advanced stage of value-based payment, health care practices receive fixed payments every year to keep the people in their communities well (with various contingencies built in for very expensive medical needs and people from outside their normal patient base who need care). That supports food-based initiatives both because it creates incentives to invest in prevention and provides maximum (although not absolute) flexibility in what can be paid for. For some additional background:

Welcome to Payment Reform - Policy in Plainer English podcast series

Editorial on Payment Reform and Food Policy (11/6/19)

Payment Reform and Food Webinar, organized by Vermont Farm to Plate - Video and Annotated Slide Deck (3/6/20)

Food and Health Care Payment Systems Panel, organized by Vermont Farm to Plate - Video and Notes (10/1/20)

 

Evidence-Based Interventions: The question isn’t only whether there is evidence behind a program, but for what condition does the evidence exist and how are patients identified as being a good potential match? The Medically Tailored Meals literature is a starting point for these types of studies.  

 

Defining Eligibility and Services: There are usually two thresholds for eligibility as regards programs that provide a significant amount of food using health care dollars, both medical necessity and financial necessity. For example, if someone needs to transition to a gluten-free diet and has no difficulty accessing and preparing gluten-free foods, then health care payers might cover nutrition counseling to design the appropriate diet, but not the food itself. If someone cannot access this food easily, then health care payers might cover supplemental food kits in addition to nutrition counseling.
 

Benchmarking for Price: Health care has a tricky relationship with cost-based reimbursement. There’s history there. Even if food as a covered service means paying the reasonable costs of providing that food, programs are not uniformly designed and so it is difficult to standardize for what a reasonable cost would be. This Commonwealth Fund review of the process of setting the North Carolina Healthy Opportunities pilot fee schedule is a good starting point for understanding what a price setting process might look like.


Administration: Reimbursing for health care services isn’t as simple as ringing up a food order at the cash register. For traditional services, to get paid requires a lot of steps - credentialing providers, knowing what provider types can bill which services to what insurance policy, structured documentation of the service provided, understanding cost shares and co-pays, navigating prior authorization requirements, adjudicating denied or disputed claims. . . and so on. It’s an entire industry unto itself. Somewhere someone has to decide the technical details of how food fits into this structure


Timeline for Impact: Not all health care programs need to have an impact tomorrow, but longer term programs need to be paid for with longer term money - an employer- funded commercial premium isn’t necessarily a good fit for a prevention program that will improve health a generation from now but will be for a program that prevents illness in their employees today. It is common for both practices and payers to have to meet certain quality and cost measures assessed on an annual basis. When connecting to reimbursement structures, it’s important to have a sense of how quickly a particular food program will show results in either improved clinical measures or reduced health care costs at an equal (or better) quality level. This is one reason why food as medicine research often focuses on measures like the “30 day readmission rate” for patients after a hospital stay - it’s a high impact area for food programs: patients usually have a strong desire to avoid hospital readmission, hospitalization is expensive, and it’s a short time frame for results.  

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