Project Bread Teams With Mass. Medicaid ACOs on Food Insecurity
Massachusetts food security organization Project Bread works with MassHealth’s Health-Related Social Needs (HRSN) program and community health centers statewide to provide support to patients with health issues exacerbated by food insecurity. Executive Director Erin McAleer recently spoke with Healthcare Innovation about its partnerships with Medicaid ACOs.
Healthcare Innovation: How did a nonprofit focused on food insecurity get involved in the state Medicaid program?
McAleer: The work that we're doing in the healthcare space is possible because of the policies at the state level, with our Medicaid waiver in Massachusetts. Project Bread is about 55 years old. We are focused on putting forward solutions that will permanently end hunger. We do direct service work. We are connecting people to households who are food-insecure, but all of our work is focused on the North Star — how do we prevent this in the first place? On the healthcare side, we're serving about 8,000 patients per year, but we're also doing research, focus groups, and data collection to make the case that this program should be a permanent part of Medicaid, which it did become in Massachusetts on Jan. 1, and to advocate for expanding it even further.
HCI: You mentioned the Medicaid waiver. Can you talk a little bit about MassHealth’s Health-Related Social Needs program and what happened during the pilot period?
McAleer: In Massachusetts, we have proudly led on universal access to healthcare, but also have been really leading on how we can reduce healthcare costs as a state. Our state recognized early on that there are certain social determinants that if they are not addressed increase costs of healthcare, and one is access to food. If people don't have access to healthy food, it really doesn't matter how much medication you're giving them or doctors visits they have. So our state took the unique approach of leveraging the Section 1115 waiver and asking the federal government to pay for non-medical expenses in Medicaid. We at Project Bread launched our program in 2020 under that waiver. We had planned to launch it in July of 2020 but with the pandemic, we ended up launching it early in April of 2020 just because the health centers were seeing such an increased need.
HCI: Perhaps it was good timing that you were preparing to launch then because the need became so great so suddenly.
McAleer: Yes. But when we first saw this program, we thought that it didn’t make sense for us, because everybody was reading it as food would be the reimbursed piece, and we're not a food pantry or a food bank. There's no food preparation our headquarters. But we had conversations with Medicaid in our state, and asked if we could take a different approach. Could we instead have a coordinator who works one on one with this patient, and connects them to all the different food resources? We can send them to another Project Bread program, our food source hotline, and screen them and sign them up for SNAP and WIC federal nutrition programs. We are finding well over 50% of the patients we are working with are not enrolled in federal nutrition programs.
HCI: And most of them are eligible?
McAleer: They are eligible, for the most part, yes. And because we know that's not enough, we are supplementing that with grocery store gift cards and providing nutrition counseling and cooking and kitchen supplies. When we launched our model in April 2020, we did not have kitchen supplies as part of what we had envisioned. And we learned really, really fast that it was one of the biggest barriers. We do refer patients to medically tailored meals if that's what they needed. We had a couple patients in those early months, say, ‘Please don't do that. I don't have a refrigerator. I can't store it anyways.’ So we added kitchen equipment. In that first year, a gentleman e-mailed me and was over the moon because it was the first time he owned a refrigerator in his entire life, and in his e-mail he was talking about all the foods he was now eating. He'd only been eating shelf-stable food for a really long time. So that's become a core component of the program. Over the past five years, we've served over 17,000 patients, and we have really great outcomes to show from the work done to date.
HCI: Does Massachusetts have Medicaid managed care organizations or do people get referred from provider organizations?
McAleer: We have accountable care organizations. The idea is to give you money to serve the patient, but let's try to bring patient costs down, right? So the way it works is the ACOs screen their patients for food insecurity, and they send them to Project Bread, and we serve them. Then we get reimbursed from the ACO, and the ACO is reimbursed from MassHealth.
HCI: I saw you work with Boston Children's Health ACO. Are there ACOs in other parts of the state?
McAleer: Yes, there are ACOs all over. We work with C3, which has an ACO for most of the community health centers in Massachusetts that we work with. I think Boston Medical Center is one of the biggest. We’re working with Mass General Brigham and Beth Israel.
HCI: Are there any challenges getting set up with them as far as billing or communications or sharing data about the outcomes?
McAleer: Yes, we have been a social service organization for 50 years, and that's how we were structured. We never had to be HIPAA-compliant before. Everybody who works for Project Bread — all 90 employees — have to go through training around HIPAA. We set up a Salesforce database for bidirectional data to be shared between the ACOs and Project Bread. We have to make sure that database is secure. I would say getting all of that set up was a huge undertaking for our team. It was costly as well, but also just really time-consuming. And now where we're focused is on claims processing. I share that, because I think one of the barriers to doing what we're doing for a lot of organizations is the capacity to do something like that. This requires a lot of staff capacity and knowledge. We had to hire IT consultants at various times during the project to make sure we were doing it the right way.
HCI: Several other states have Medicaid waivers and are working on food insecurity. Can you think of another state that has something that's as comprehensive or doing something very similar?
McAleer: I know that Oregon and North Carolina are doing really incredible things, but I don't think anyone is doing the full breadth of services that we do, as far as we know.
HCI: In January of this year, this switched from a pilot phase to a broader rollout. In the pilot period, were they looking for certain improved health outcomes or cost savings to measure the impact?
McAleer: Yes, definitely. And I know that some of the research that we had conducted our state government shared with CMS. Some of the research we track is around self-reported food insecurity. We saw a 19% increase in people being food secure by the end. We look at vegetable consumption, we look at increases in SNAP enrollment. We also have data from the healthcare providers, which is really valuable. One of the findings is that the healthcare providers said that their clients were just happier and better connected with their doctors. We found 84% of clients reporting high satisfaction and better connection with their doctors. What their doctors are saying to us is they're showing up for their appointment, and they’re more compliant with the healthcare plan.
On the ACO side, they obviously have more data around cost of care, and they had data showing that members had fewer visits to the emergency department. The data that came out just this week is showing a cost savings of $2,500 per adult in the program, with reductions in emergency room visits. The cost of care stuff is so persuasive and so important, because healthcare is the biggest part of our state budget or federal budget. But we also try not to lead with that too much, because we want to make the case that we should just make sure people have the healthy food that they need, just like they might need other interventions that don't result in a cost-of-care decrease. But that said, we know it's such a compelling argument to make that we are saving money by doing this.
HCI: Does the transition from the pilot phase to a broader roll-out mean a larger scale-up and more people being served?
McAleer: Yes and no. It became a supplemental benefit of Medicaid in Massachusetts. With anything in Medicaid, you can't offer services to one person and not another if they're eligible. So what they ended up having to do is sort of retract who is eligible to fit within the budget that we were getting to cover this program. So they had to get a little bit more specific in who could be eligible. They set the rates for different things, and we had to figure out what that is going to mean for all of our organizations. Now we have the rate and are assessing patient volume, and the hope is that by the end of the year it lands close to what that budget number was. But if it goes over, they're going to have to trim more. If it goes way under, that means we can expand the eligibility a little bit to bring more in. So we're still in a learning year for that.
