How do we increase the promotion of produce prescriptions in the never-ending quest to implement and integrate social determinants of health?
As of 2010, diet has surpassed smoking as the leading cause of death for Americans—which translates to hundreds of billions of dollars being spent to combat diseases stemming from poor health and diet. Data like this demonstrates the importance of changing the way we think about healthcare delivery—from focusing simply on medicinal treatments to also considering a patient’s social determinants of health (SDOH). While the concept of SDOH inclusion is not new, states continue to struggle to figure out how the cost of less traditional healthcare should be reimbursed—including integrating social determinants of health into effective, high quality care.
SDOH in Healthcare Delivery
Not so long ago, before preventative services became more mainstream, smoking cessation treatments were very costly—much like the types of services typically associated with SDOH. Many of the services now covered for smoking cessation were included within the definition of preventive services in the Affordable Care Act, providing wider, less costly access for individuals. This has resulted in varying degrees of coverage of cessation counseling, medications, and low- to no-cost sharing, depending on one’s type of insurance (commercial vs. Medicaid and Medicare populations).
As in the case of smoking cessation treatments, the overall approach to insurance plans’ inclusion of SDOH varies, as does the flexibility afforded by federal and state regulation and reimbursement methodology. There have been some recent advancements at the federal level to support the more widespread inclusion of SDOH in health plan design and operation. In 2018, the Centers for Medicare & Medicaid Services (CMS) announced new flexibility that allows health insurance carriers to add new benefits that address social determinants of health (SDOH) that complement the medical services already covered by Medicare Advantage plans. CMS also announced the Accountable Health Communities for Medicaid/Medicare plans, which asks participating physicians to “screen high utilizers of healthcare services for food insecurity, domestic violence risk, and transportation, housing and utility needs.” In recognition of the fact that these factors play a huge role in a patient’s overall health, Accountable Health Communities sets patients up with “navigators, who can help determine what resources are available in the community to meet the patient’s needs” as a vital part of their treatment plan. As of publication, there were thirty organizations participating in the Accountable Health Communities Model five-year pilot program.
CMS noted that this program was modeled off of the Accountable Care Organization (ACO) model of care delivery, which has made significant efforts to link SDOH to quality measurement—in particular, improving patient nutrition/nutritional education as a way to both drive down healthcare costs and target care in a high-quality manner. What hasn’t yet happened, except on a very small scale, is linking SDOH to direct access to foods proven to assist individuals in actionably improving their diet. In fact, CMS specifically notes that the funds for the Accountable Health Communities Model “do not pay directly or indirectly for any community services (e.g., housing, food, violence intervention programs, utilities, or transportation).” However, with federal funding recently appropriated for a pilot fruit and vegetable prescription program, and commercial insurance recognizing the importance of improved access for high-risk populations, as well as those at risk for food instability, the move toward more coverage for fresh fruits and vegetables may be underway.
Impact of Produce Prescription Programs
The 2018 version of the Agriculture Improvement Act of 2018, aka the “Farm Bill,”  builds upon and expands the existing Food Insecurity Nutrition Incentive program. Renamed the Gus Schumacher Nutrition Incentive Program in 2018, Food Insecurity Nutrition Incentive programming had previously been appropriated $100 million for nutritional incentives for people relying on Supplemental Nutritional Assistance Program (SNAP) in a 2014 bill. The 2018 Farm Bill appropriates $25 million over 5 years for competitive grant programs that provide prescriptions (“RX”) aimed at produce consumption. These pilot programs will not require a 50% non-federal match, but will need to be supported by data to assess whether the program’s approach reduces healthcare spending.
Despite evidence showing the connection between economic incentives and prescribing fresh produce for both low-income and high-risk health populations, federal funding for these programs has been tough to secure. In a recently released microsimulation study of a food and vegetable prescription program, the results showed that a fruit and vegetable prescription program could save an estimated $40 billion in healthcare costs. More importantly, the microsimulation indicated produce RX programs would prevent over three million cardiovascular cases, and over a half a million cardiovascular deaths. The benefits of a fruit and vegetable prescription program were consistent across payers (public/private), as well as socio-economic status, race, age, income and SNAP participation.
The Wholesome RX Model
With no plan in place for widespread implementation of food RX programs, states and non-profits are leading the way in increasing access for populations to fresh produce. One organization in particular has been pivotal in the promotion of fruit and vegetable RX programs: Wholesome Wave. Since 2010, Wholesome Wave has been working to assist physicians in writing RXs for produce, as well as creating community partnerships that allow patients to utilize the RXs for produce in stores.
While the use of SNAP benefits has been rolled out for use at farmer’s markets and other locations, these offerings tend to be only seasonally available in some areas of the country. Wholesome Wave, on the other hand, aims to provide a more permanent means for access to fresh fruit and vegetables. In addition to working to secure inclusion of a produce prescription program in the 2018 Farm Bill, the team at Wholesome Wave operate the Wholesome RX program. The Wholesome RX program connects physicians and patients with locations where prescriptions for fruits and vegetables can be redeemed. The program works by partnering with physicians, who enroll patients, for a period of months, to receive a prescription providing up to $1 dollar a day per household member toward produce. These prescriptions can then be redeemed at participating supermarkets and grocery stores—partnerships secured via Wholesome Wave working with supermarkets and stores in the area.
Other Produce Prescription Programs
Hospitals and community health centers continue to innovate in order to address their patient population’s SDOHs. One such example is the Pennsylvania-based Gesigner Health System’s establishment of a Fresh Food pharmacy. Gesigner pairs patients that are identified as having HBA1C levels greater than 8 (and/or food insecurity) with clinical care management, diabetes education, and consultations with dieticians and pharmacists. In additional to this clinical support, patients are also provided with kitchen supplies (measuring cups, spoons, recipes) and fresh food in order to prepare nutritious meals (typically enough food to make two meals for five days a week) for their whole family at home. The Gesigner Fresh Food Farmacy program operates in conjunction with local non-profits, including a food bank, to deliver a more holistic approach to the treatment of diet-related disease prevention and treatment.
While non-profits and community health providers have operated smaller-scale, local produce access programs, even large commercial insurance carriers are seeing some value in ensuring access to healthy food. Blue Cross Blue Shield (BCBS), in conjunction with the BCBS Foundation, recently announced a pilot expansion of a food delivery service program, foodQ, currently targeted at individuals living in zip codes in the Chicago and Dallas areas designated as “food deserts.” This BCBS pilot program delivers two full meals a week for a $10 monthly service fee, with free delivery. If this six-month pilot program is successful, BCBS seeks to expand operation to other regions. As the president of the BCBS Institute stated, “as a physician, I know I can easily write a prescription, but what I don’t know is how am I going to make sure patients have access to healthy meals they can afford and want to eat” This is the problem that food and vegetable prescription programs seek to alleviate: providing patients with the low- or no-cost access to the food, fruits, and vegetables they need to actually change their diet and improve health after the prescription is written.
Be sure to visit the blog for updates on this topic- including insights from our interview with key staff members at Wholesome Wave, and details of a pilot program in New York City that provided produce prescriptions to thousands of New Yorkers.
(Note: Research assistance provided by Eliza Hilfer, Tufts University- Class of 2020)