Medically Tailored Meal Delivery Improves Outcomes, Cuts Costs

Diana Phillips

April 22, 2019

Providing medically tailored meals (MTMs) to individuals with complex medical conditions and food insecurity can improve downstream health outcomes, ultimately reducing rates of admission to inpatient care or skilled nursing facilities in this population, new data suggest.

The findings support the argument for better integration of nutrition into healthcare delivery and payment systems, Seth A. Berkowitz, MD, University of North Carolina at Chapel Hill School of Medicine, and colleagues report in an article published online today in JAMA Internal Medicine.

It has been suggested that MTMs, which are meals prepared under the supervision of registered dietitian nutritionists to meet patients' specific nutritional needs, may improve health and lower healthcare use and cost by improving recipients' nutrition, but the association has previously only been examined in small studies with restricted sample sizes.

To test the hypothesis more broadly, Berkowitz and colleagues linked data from the Massachusetts All-Payer Claims Database for 2011–2015 with service delivery records from Community Servings, a not-for-profit food and nutrition organization that delivers MTMs in Massachusetts to individuals with serious medical illness. They identified individuals with complex medical conditions (such as HIV, cancer, end-stage renal disease, or congestive heart failure) who participated in the MTM program and a matched population (based on individual sociodemographics, comorbidities, and neighborhood characteristics, and preintervention healthcare use) of individuals who did not receive the meals.

The primary outcome of interest was inpatient admissions, which, under the researchers' conceptual framework, were likely to be reduced with the meal program. Secondary outcomes included admission to a skilled nursing facility and total healthcare costs.

The MTM intervention consists of 10 meals per week, with program eligibility based on certification of nutritional and social risk.

After matching and adjustment, the study sample included 499 MTM recipients and 521 nonrecipients; the median duration of MTMs was 9 months.

Compared with nonrecipients, MTM participation was associated with approximately 49% fewer inpatient admissions (95% confidence interval [CI], 20% - 78%) and 72% fewer skilled nursing facility admissions (95% CI, 40% - 99%) over nearly 2 years of follow-up. The savings in total healthcare costs, including the cost of program participation, was calculated to be approximately $753 per person per month. 

"This difference represents approximately 16% lower health care costs," the authors write.

Although the findings support those of previous, smaller studies linking MTM and healthcare costs and outcomes, the authors stress the importance of understanding them in context. "[I]ntervention recipients were those with clinical, nutritional, and social risk factors that interacted to produce a high short-term risk of clinical deterioration if they did not receive nutritional intervention," they write. "Although these risk factors are a common combination, we caution against overgeneralizing the results of this study to other contexts."

According to the authors of an invited commentary, "MTMs may represent the tip of the spear for a national evolution toward such food-is-medicine approaches," Dariush Mozaffarian, MD, DrPH, and colleagues from the Friedman School of Nutrition Science and Policy, Tufts University, Boston, write.

Based on the estimated advantages, MTMs and other food-based healthcare interventions "warrant expanded evaluation, at scale," to understand the true health and economic benefits of MTMs, the commenters write. They note that this work has started in some areas, including California, where the state is testing the health and use effects of MTMs in a $6 million intervention across 6 counties. In addition, various nonprofit organizations are supporting MTM programs and other initiatives.

"For full scale implementation and effect, such interventions will need to be integrated into large private and public insurance programs," the editorialists stress.

"As health care professionals move toward accountable care, risk-sharing payment models should invest in nutrition for meaningful cost savings and improved patient outcomes. All of these programs should include special focus on vulnerable and sensitive groups and address social determinants of health."

According to the study authors, the findings have implications for health policy. "Medicaid programs in several states have piloted MTM delivery in various settings, and Medicare Advantage recently made changes that could allow coverage for some meal delivery programs," they write.

Further research, through large-scale clinical trials, is needed to clearly assess the benefits of MTM participation, the authors note. Also, programs should target populations with the greatest need as these individuals will be most likely to benefit. "A rigorous evidence base that elucidates when MTM programs are needed will be necessary for efficient use of health care resources," they write. "Ultimately, a range of options that vary in cost and level of service provided may be needed."

Two of the study authors are employees of Community Servings, the MTM service provider in Massachusetts. Coauthor John Hsu reports financial relationships with Community Servings, Delta Health Alliance, DaVita Health Care, the University of California, and the American Association for the Advancement of Science.

The authors of the invited commentary report financial relationships with the Bill and Melinda Gates Foundation, GOED, DSM, Nutrition Impact, Pollock Communications, Bunge, Indigo Agriculture, Amarin, Acasti Pharma, America's Test Kitchen, Omada Health, Elysium Health, DayTwo, UpToDate, the National Institutes of Health, Unilever R&D, Nestle, Danone, and World Bank.

JAMA Intern Med. Published online April 22, 2019. Full text, Editorial

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