Insights Shared by Community-based Organizations and Payers

Both sets of interviews explored examples of successful community-based organization-health care Food is Medicine partnerships; systems-level support needed to make community-based organizations more competitive in the Food is Medicine space. Below are key takeaways from the interviews, organized by the main topics discussed.

Characteristics of successful community-based organizations-health care partnerships

• Partnerships that are a natural, rather than a forced, fit
• Partnerships in which partners are in close proximity and champions in their respective spaces
• Food is Medicine initiatives that start with and build on reimbursement from Medicaid, whose beneficiaries are often included in an initiative's intended populations

Most helpful types of involvement from payers in Food is Medicine initiatives

• Sustainable funding and infrastructure-community-based organizations often spend time in constant grant writing cycles that take away from capacity to implement Food is Medicine initiatives
• Data sharing and analysis-community-based organizations often lack HIPPA-compliant data infrastructure or lack research and evaluation expertise and capacity, so CBOs look to payer partners to fill this role
• Trust-building in the intended impact community
• A demonstrated whole-patient care approach

Least helpful types of involvement from payers in Food is Medicine initiatives

• Unwillingness to take a risk and try something innovative, instead waiting for their payer peers to innovate first or waiting for a mandate from Centers for Medicare & Medicaid Services (CMS)
• Lack of understanding, appreciation, or willingness to provide funding or infrastructure for wraparound services like enrollment in federal assistance programs, homelessness prevention, and transportation as part of Food is Medicine initiatives
• Forced use of Food is Medicine initiatives where they do not make sense. For example, in some scenarios, leveraging SNAP, WIC, or other programming might be more relevant than a Food is Medicine initiative

Challenges to working with payers

• Lack of consistent technology across Food is Medicine partners and the inability of different technology systems to “talk” to each other
• Lack of a uniform model or streamlined workflow for Food is Medicine initiatives
• Lack of a sustainable and reliable funding source
• Payers' lack of understanding or awareness of how Food is Medicine fits within the larger framework of social determinants of health
• A “push-pull” between pressures to both scale up and provide more tailored programming, for instance interventions that are culturally relevant, serve pediatric populations, and serve pregnant populations. Community-based organizations may end up providing tailored programming not because they have the right experience or ability but because they are responding to a guaranteed funding source. This ultimately does not benefit the intended populations.

Ideas for bridging gaps in CBO-health care partnerships

• Investment in a streamlined technology system (e.g., Coding4Food project[2]) that creates new Healthcare Common Procedure Coding System (HCPCS) codes to integrate a spectrum of Food is Medicine interventions into the health care system
• What community-based organizations would like to better understand about payers and health care entities
• Payers' priorities for funding and programming that would allow community-based organizations to best position themselves to be a partner for health care providers
• Barriers like time and training that discourage health care providers from investing in Food is Medicine initiatives, and how those barriers can be bridged
• Which tools exist to create projections of reduced health care costs and utilization, and how community-based organizations should leverage them. Related, the risk that due to lack of understanding of these types of data, community-based organizations may overpromise on outcomes.

What community-based organizations would like to better understand about payers and health care entities

• Payers' priorities for funding and programming that would allow community-based organizations to best position themselves to be a partner for health care providers
• Barriers like time and training that discourage health care providers from investing in Food is Medicine initiatives, and how those barriers can be bridged
• Which tools exist to create projections of reduced health care costs and utilization, and how community-based organizations should leverage them. Related, the risk that due to lack of understanding of these types of data, community-based organizations may overpromise on outcomes.

What community-based organizations think health care organizations may misunderstand about them

• Payers' priorities for funding and programming that would allow community-based organizations to best position themselves to be a partner for health care providers
• Barriers like time and training that discourage health care providers from investing in Food is Medicine initiatives, and how those barriers can be bridged
• Which tools exist to create projections of reduced health care costs and utilization, and how community-based organizations should leverage them. Related, the risk that due to lack of understanding of these types of data, community-based organizations may overpromise on outcomes.

What makes community-based organizations appealing to payers

• They run high-touch, tailored programming, rather than the one-size-fits-all approaches
• They have built durable trust and rapport in impacted communities
• They can address more than just nutrition-community-based organizations can also address equity, cultural relevancy, and provide wraparound services and referrals.
• They naturally help with public relations, because they are good at storytelling to diverse audiences

Payers

Most important roles of community-based organizations in Food is Medicine work

• Provision of services that improve health care costs
• Fulfillment of food benefits; responding to community needs
• Partnerships with local and regional health care payers and systems

How community-based organizations can best coordinate with payers to engage in Food is Medicine initiatives

• Show that they can reduce total cost of care
• Collaborate with multiple community-based organizations to engage collectively with payers and systems to cover larger regions
• But this remains a challenge-there may be no easy roles in the current system for community-based organizations at large scale

Challenges to working with community-based organizations

• Gaps in community-based organizations business capacities, including data security, contracting, and food sourcing
• Missing system-level infrastructure, including infrastructure to support data sharing and management
• Missing system-level entities such as community care hubs and social care networks to ease payers' burden of contracting, referrals, and billing with multiple community-based organizations
• Community-based organizations' small or moderate capacity requires payers to contract with multiple community-based organizations to serve members at scale

Community-based organizations' misunderstandings about payers

• They may not perceive that payers care about other metrics beyond per member per month cost
• They may not perceive that many health care systems are losing money
• They may not perceive that payers are experiencing significant financial challenges, up to struggling to make payroll
• They may not perceive that many payers believe the business case for Food is Medicine has not yet been made
• If a Food is Medicine service is not improving health outcomes and lowering cost of care, then that service is adding cost to health care. Community-based organizations may not perceive that this means adding money to pay for that service, which could mean higher premiums in commercial insurance
• Community-based organizations may not perceive that data showing that Food is Medicine services reduce food insecurity-in, for example, patients with diabetes, a population with a strong association between food insecurity and higher health care costs-does not by itself convince payers that reducing food insecurity will necessarily reduce health care costs
• Community-based organizations may not anticipate that establishing contracts with payers is a slow process. When payers contract with multiple community-based organizations, establishing contracts becomes even slower.

How community-based organizations can make their case to payers

• Show that the organization's service can help control payer cost
• Show the full cost to the payer of the organization's service at scale
• Show that the community-based organization can partner with others to provide services over a wide geography
• The nuances of case-making depend on which health insurance line of business is being discussed: Medicaid vs. Medicare vs. commercial insurance. In addition to cost, relevant indicators include improvements in Healthcare Effectiveness Data and Information Set (HEDIS), quality “star” ratings, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures.
• Insurance data is not perfect, and there is only so much case-making a community-based organization can do without access to data that most insurance companies will continue to keep as proprietary. An alternative approach to each single organization's trying to prove cost-savingsis to show that a community-based organization is part of a collective that can provide efficient and high-quality service across an entire geography of interest to the payer.

Payer misunderstandings about community-based organizations

• Payers may perceive that community-based organizations have more flexibility than they do
• Payers often want programs that run for longer periods of time, which is generally impossible without significant funding. Or payers want programs to show dramatic change like biomarkers or health care cost within a very short period of time.
• Payers do not understand or appreciate the full scope of what community-based organizations can do: outreach, engagement, nutrition education, follow-up, and quality improvement, to name prominent examples.
• A related problem is payer ambitions vs. CBO realities of scope and scaling, Community-based organizations cite payers as sometimes wanting an "Amazon.com" model of scope and scale.