Medicare Advantage Initiative to Improve Social Determinants of Health

Food insecurity is one of the major social determinants of health that refers to restricted access to nutritious food. Even in developed countries like the United States (US), a significant proportion of older adults - approximately 4.3% to 7.1% - experience food insecurity. ^1,2 Additionally, 5 million older adults in the US live in food deserts,³ which are low-income geographical areas where residents have limited access to grocery stores or healthy and affordable food stores. Food insecurity can significantly impact the health and overall well-being of older adults, especially after being discharged from the hospital.^4,5 During hospitalization, older adults often experience malnutrition due to reduced nutrition intake and hospital associated deconditioning, leading to decline in physical function.^6–8 Additionally, older adults are at a higher risk of developing frailty and experiencing a poor recovery due to inadequate nutrition after hospitalization.^9,10 This decline in physical function can make it difficult for older adults to perform everyday tasks, like preparing meals. Furthermore, low-income older adults who are physically disabled may struggle to access grocery stores after being discharged due to a lack of reliable transportation.

The 2018 Chronic Care Act has paved the way for Medicare Advantage (MA) privately run insurance plans to address social determinants of health by offering supplemental benefits such as transportation services and meal benefits, including nutrition education, cooking classes, and home-delivered meal services.¹¹ Offering meals to older adults with chronic conditions following hospitalization has demonstrated to be a promising solution for decreasing expensive hospital readmission and mortality.^12,13 Initial research has outlined the potential advantages of home-delivered meal services, making it a feasible choice to assist in keeping high-risk older adults in the community and reducing healthcare expenses.¹⁴ As the number of MA enrollees continues to soar and more MA plans offer home-delivered meal services, it is crucial to understand factors associated with the delivery of meal services and ensure that these meal services meet patients’ dietary needs.¹⁵

In this issue of the Journal of the American Geriatrics Society, Richards et al. examine the association between socioeconomic factors, food insecurity, and patient satisfaction with home-delivered meal services.¹⁶ The study aims to provide insights into improving factors associated with the uptake of home-delivered meal services for patients’ nutritional needs and satisfaction. The study population included 2,454 older patients enrolled in the MA program from January to December 2021 who were referred to home-delivered meal services after being discharged from the index hospital. Of the 2,454 patients referred for post-hospitalization meals, 62% received at least one shipment of meals. Racially or ethnically minoritized older adults and those who had previously received medical financial assistance were more likely to accept the meals. However, older adults with longer hospital stays and do-not-resuscitate status were less likely to accept the meals, indicating that these factors may influence the acceptance of such programs. It is important to note that these patients are often seriously ill and may have unique nutritional needs. Therefore, MA plans have an opportunity to address the nutritional needs of high-risk patients. Of the 665 patients who completed the meal satisfaction survey referred for post-hospitalization, 69% were satisfied with the home-delivered meal services. Patients experiencing food insecurity and those with good health status are more likely to report satisfaction with the home-delivered meal services.

These findings align with results obtained from recent research on Meals-on-Wheels and medically tailored meal program.^14,17 Previous studies on Meals-on-Wheels have demonstrated that the program’s beneficiaries exhibit a diverse range of characteristics, including age, ethnicity, marital status, living arrangements, food insecurity, and physical disability.¹⁸ The research conducted by Richards et al. sheds light on the factors that are linked to the adoption of home-delivered meal services.¹⁹ It also highlights the factors that can be addressed to enhance satisfaction level with home-delivered meal services.

Given that MA plans tend to have higher percentage of dual-eligible beneficiaries (enrolled in both Medicare and Medicaid) than the traditional Medicare Fee-for-Service (FFS) program, the lower uptake of home-delivered meal services among dual-eligible beneficiaries is concerning.²⁰ Dual-eligible older adults usually have a higher number of comorbidities and physical and cognitive impairments and are disproportionately affected by poor health.²¹ Additionally, they are disproportionately from racial/ethnic minoritized groups with low socioeconomic status.²¹ All these risk factors put dual-eligible older adults at higher risk of food insecurity²² and malnutrition-related complications. Thus, limited intake and access to nutritious food is a particular concern for dual-eligible patients and can negatively impact their health following hospitalization. This, in turn, can lead to increased use of costly health services such as emergency department visits, hospital readmissions, and long-term initialization.¹⁴ The poor association could be due to a small number of dual-eligible patients in the study cohort, which does not represent the national sample in the MA program.

This study examined various clinical and socio-economic factors that might have contributed to the uptake and overall satisfaction with home-delivered meal services. The study highlights the significance of social risk factors at the individual level, such as spoken language, prior medical financial assistance, anticipated post-discharge support, and medical severity variables, including readmission risk score, resuscitation code status, and laboratory acute physiology score. Additionally, physical and cognitive status is an important clinical factor that can prevent older adults from accessing grocery stores and preparing meals. Further research is needed to understand the relationship between cognition and uptake of home-delivered meal services. Although the study sample size was relatively small and the uptake cohort was only a subset of patients, which may have led to sampling bias, the study highlights the need for further investigation on the uptake and satisfaction of home-delivered meal services. This could include looking at factors such as nutritional ingredients, culturally-tailored cuisine, or medically-tailored meal status. Given that MA beneficiaries are more racially or ethnically diverse, including Asians and Hispanic older adults, it is worth exploring the delivery of culturally tailored food in their meal plans.

The findings of the study have significant implications for the ongoing debate on the growth of MA enrollment and the increasing number of low-income dual-eligible beneficiaries and racially or ethnically minoritized older adults in MA plans.^11,23 As the proportion of racially or ethnically minoritized older adults and dual-eligible beneficiaries increases in MA plans, more services need to be designed to address social determinants of health. In contrast to MA plans, FFS programs do not cover supplemental benefits that are crucial in addressing social determinants of health in high-need and high-cost older adults. The study’s findings provide an opportunity for the FFS program to incorporate supplemental benefits like home delivery of meals and transportation services as potential tools to improve food security, healthcare utilization, and outcomes in high-need and high-cost older adults. Furthermore, these policies could prioritize low-income and marginalized older adults, particularly those belonging to racial or ethnic minoritized groups, resulting in better health equity.