“The last time I looked in my textbook, the specific therapy for malnutrition is food.” That response was given by Jack Geiger, who helped create the community health center model in rural Mississippi in the 1960s. He had been challenged for buying food for patients and charging it to his center’s pharmacy budget. His retort became a rallying cry for social needs activists, who loved Geiger’s combination of rebelliousness and common sense.
Nevertheless, in most health care organizations, Geiger’s argument for meeting patients’ social needs has been more rhetoric than reality — that is, until recently. Despite political uncertainty from Washington, health care is moving away from its focus on fee-for-service and toward value, i.e., meeting patients’ needs as efficiently as possible. To do so, many providers are developing systems to detect and meet patients’ unmet needs.
Concentrating the Research Focus
It’s new work, and it’s hard work. It’s usually unfunded work. But it works.
At least it can work, when pursued with the same discipline with which researchers might test a new drug: focusing on a well-defined population with a good chance of showing benefit if the intervention is effective. At Geisinger Health System, we understood the risks of trying to “boil the ocean,” and instead tried to see what was involved in meeting just one social need in just one population. We decided to concentrate on diabetes, a condition that affects 11.3% of the population in Pennsylvania, which is higher than the national average. We wanted to work out administrative procedures in which we provided healthy food as if it were a drug and started a program in 2016 called Fresh Food Farmacy.
We focused on food because research suggests that food insecurity, or lack of access to nutritionally adequate food, is one of the most important risk factors for developing type 2 diabetes. Food-insecure adults are two to three times more likely to have diabetes than adults who are food secure. And food insecurity is widespread; more than one in eight American adults and one in six children is food insecure. People with severely limited incomes often turn to inexpensive, easily accessible food that is rich in calories and poor in nutrients, which can cause and exacerbate diabetes.
Directly Dealing with Food Insecurity
The key steps in our program: First, we screen for food insecurity. Then, we give away free, nutritious food. Along the way, we teach our patients about their disease and how to manage it.
Geisinger based its program upon two optimistic assumptions: first, that eating healthfully improves health, and second, that people want to eat better but may not know how to or have the means to do so.
The target patients eligible for Fresh Food Farmacy are adults whose type 2 diabetes is not well controlled. They must also answer “yes” to at least one of two questions that screen for food insecurity: (1) “Within the past 12 months I/we worried whether our food would run out before we got money to buy more,” and (2) “Within the past 12 months the food I/we bought just didn’t last, and we didn’t have money to get more.” Data were collected via our EMR searching for diagnosis of type 2 diabetes with elevated sugars out of control typified by a blood test measurement of hemoglobin A1c (HbA1c) ≥8. Patients were screened for food insecurity electronically (via the patient portal), by phone, or in person when at a clinic visit. Of 458 patients screened, 128 patients were found eligible for the Fresh Food Farmacy, and 95 patients were enrolled.
Exploring Program Components
The “Farmacy” for this program is a food pantry built in a Geisinger clinical center in Shamokin, Pennsylvania. It provides enough fresh fruits and vegetables, whole grains, and lean proteins to feed program participants and their entire household two healthy meals 5 days per week each. Patients are also given a weekly menu and recipes to help them learn to use ingredients that may be unfamiliar to them.
Once enrolled, participants are required to attend 15 hours of group classes. They learn basic concepts about their disease, including: What is diabetes? How do you get it? What is blood sugar? And how does my diet affect my blood sugar? The goal is to give patients a better understanding of their diabetes, so they increase their ability to care for themselves.
Participants also have access to a care team that includes a nurse, primary care physician, registered dietitian, pharmacist, health coach, community health assistant, and administrative support personnel. The team offers services to help patients sustain their lifestyle improvements, including direct medication-management assistance; nutrition counseling; health coaching; and ongoing case management to address transportation, family care, and other challenges that can make engagement difficult.
Our initial pilot was limited to six patients. Within 9 months, we scaled up to include 50 patients. As of March 2018, we are serving 112 patients/households, feeding an average 336 people per week, which amounts to 3,360 meals per week or 174,720 meals per year. One of our goals is to reduce the meal gap in our community, and extending free food to those in the patient’s household is helping with that.
We currently fund the program through grants (40%), in-kind reciprocal contributions with Geisinger Health System (30%), and private donations (30%). Geisinger provides in-kind administrative support and rent-free space for the food pantry and clinical areas, though we anticipate that, as we expand, it’s likely that the program will pay rent.
Delivering Clinical and Financial Results
In 18 months, this approach has led to a drop in HbA1c levels from an average of 9.6% before enrolling in the program to 7.5%. To put this change in perspective, diabetes patients who take two or three medications can expect their HbA1c to drop between 0.5 and 1.2 percentage points. The average 2.1 percentage point drop in HbA1c levels is a better outcome and corresponds to a more than 40% decrease in their risk of death or serious complications.
Because many of the participants are insured by Geisinger Health Plan, health care spending data are available for 37 of our patients. Thus far, claims data shows costs for our pilot patients dropped by 80%, from an average of $240,000 per member per year, to $48,000 per member per year. These data come from a small sample of patients, of course, but the enormous baseline annual cost suggests that the combination of factors that defined eligibility (poorly controlled diabetes, screening positive for food insecurity, and willingness to enroll in the program) identifies an extraordinarily sick and costly population. We assume that Geisinger case managers were most relentless in encouraging their sickest patients to undergo screening for the program, thus further skewing the population toward high costs, so some of the decrease in costs could reflect “regression toward the mean.”
Nevertheless, the large drop suggests considerable potential to improve health via a program with operational costs of about $2,400 per patient per year. Is free healthy food the driver of this improvement in health and reduction in costs? Or is it the education and case management that come with that food? We don’t know, but we suspect that there is synergy and would not want to separate them.
From a financial perspective, one could argue that most of the program cost (i.e., the care management team) is consistent with standard of care traditional diabetes disease management, and those costs are consistent with traditional care. The acquisition costs to the program’s “specialty drug” — free healthy food — averages about $6 per person per week. (Yes, that’s about 60 cents per meal for 10 meals. We purchase about 60% of the food through the local food bank, and about 40% through retail providers for fresh fruits, vegetables, and fish.) If a new diabetes drug became available that could double the effectiveness of glucose control, it would likely be priced considerably higher than $6 per week (and if it wasn’t, the pharmaceutical firm’s stockholders would be in revolt).
There are ancillary costs to the program, but ancillary benefits as well. Fresh Food Farmacy is feeding entire families because, well, feeding only the participants is impractical when they eat with their families. Patients have had significant improvements in their cholesterol, blood sugar, and triglycerides and many are asking for help in other areas, such as becoming more physically active and quitting smoking. The health benefits to family members have not been part of the evaluation to date, but they will be assessed in the future.
Some might call the Fresh Food Farmacy a nontraditional approach to diabetes, but if one considers fresh healthy food to be the equivalent of a drug covered by insurance and provided by the health care system, then this is essentially a disease management program — just more successful than most. And, without systems for its appropriate, effective, and efficient use, fresh healthy food is no better than any medication. Our experience suggests that by detecting the patients most likely to benefit from the program and meeting their needs, we can reduce hunger in our communities while improving the health of our patients.